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iL^^assi

OIOT OP

SAM FRAMCISOO COUSTt MEDICAL

SOCIBTY.

f l>

SfiSi^afisi

OIPT 0?

SAH FRAMCISOO nOUHTY MEDIOAL

SOOIBTY.

ELECTRO-Hv^MOSTASIS

OPERATIVE SURGERY

ALEXANDER J. C. SKENE, M. D.. LL D.

Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. ;

formerly Professor of Gynecology in the New York Post-Graduate Medical

School ; Gynecologist to the Long Island College Hospital ; President of

the American Gynecological Society, 1887 ; Corresponding Member of

the British, Boston, and Detroit Gynecological Societies, of the

Royal Society of Medical and Natural Sciences of Brussels, of

the Obstetrical and Gynecological Society of Paris, and of

the I^ipzig Obstetrical Society ; Honorary Member of

the Edinburgh Obstetrical Society ; Fellow of the

New York Academy of Medicine ; ex-President

of the Medical Society of the County of

Kings ; ex- President of the New York

Obstetrical Society

NEW YORK
D. APPLETON AND COMPANY

1899

\c.^

• •

•••

'• •

• •

• • •

JOHN BYRNE, M. D., LL. D., M.R.C.S.E.,

AS AN ACKNOWLEDGMENT OF HIS

ORIGINAL AND MOST VALUABLE CONTRIKUTIONS TO

THE SCIENCE AND ART OF THE ELECTRIC CAUTERY IN SURGERY ;

HIS SUPREME PROFESSIONAL HONOR, HONESTY, AND COURTESY;

AND IN PERSONAL GRATITUDE FOR

HIS TRUE AND CONSTANT FRIENDSHIP,

THESE PAGES ARE INSCRIBED BY

THE AUTHOR.

MOSS

PREFACE

This contribution relating to electro-hitmostasis and the
electric cautery in general and special surgery, is issued to
supplement the thii'd edition of my work on diseases of
women, in which the subject was referred to, but altogether
too briefly discussed.

The interest manifested by the profession in this sub-
ject, the employment of the new methods of operating in
other than gyniecological surgery, a number of recent im-
provements in instniments and in tlie technique of opera-
ting, and a larger exjierieuce coufinnatory of the value of
the principles and practice advocated, both prompted the
undertaking and raise the hope that the results will be
acceptable to the profession.

The part of the work devoted to electro-hsemoatasis may
appear to be rather aggressive, not to say revolutionary, and
therefore it might be judicious to give in this preface a
statement explanatoiy of the principles involved and a
preliminary argument in their favor ; but past experiences
remind me that it is unnecessaiy to do so.

In former contributitms to medical literature I have
avoided all declamations and special pleadings regarding
the merits of that which I had to offer, in order that I
should have the opinion of the pi-ofession to guide me to
rational conclusions regarding the value of my work.

vi PREFACE.

Having fared well in the past, I am perfectly satisfied
to leave the present effort to the judgment of those for
whom these pages were written — the thinking, reading,
working members of the medical profession.

My grateful acknowledgments are due to Dr. R. L.
Dickinson for taking charge of the illustrations, which
speak for themselves ; to Dr. W. H. Seymour for his val-
uable laboratory work and demonstraticms of the process
of electro-haemostasis ; and to Louis M. Pignolet, the maker
of the electrical instruments.

CONTENTS

CHAPTER PAO»

I. — Introduction 1

IT. — Description of instruments 9

III. — Results of this HiEMOSTATic process 21

IV. — Electro-h^mostasis in ovariotomy 30

V. — ELECTRO-Hi«MOSTASIS IN MYOMECTOMY AND ABDOMINAL HYSTERECTOMY 39

VI. — Electro-h^mostasis in ovario-salpinqectomy 49

VII. — Electro-h.«mostasis in appendectomy 57

VIII. — Treatment of cancer of the uterus by the electro-cautery

AND HiEMOSTASIS 66

IX. — The electro-cautery in the treatment of pelvic abscess and

diseases of the vulva and vagina 85

X. — Electro-h.emostasis in extirpation of the mammary and lym-
phatic glands 95

XI. — Electro-h.emostasis in extirpation of tumors of the bladder . 102

XII. — The electro-cautery in the treatment of urethral affections. 113

XIII. — ElECTRO-H.«MOSTASIS in the treatment of rectal HiEMORRHOIDS . 120

XIV.— The treatment of neoplasms of the skin and mucous membranes

WITH THE electro-cautery AND ELECTROLYSIS .... 129

XV. — Asepsis and antisepsis in surgery 136

XVI. — Asepsis and antisepsis (continued) 156

LIST OF ILLUSTRATIONS

NO. PAGE

1. Electro-haemostatic forceps 9

2. Electro-haeraostatic forceps chamber 10

3. Electro-haBmostatic forceps chamber 10

4. Transformer 11

5. Flexible cable 12

6. Portable storage battery 14

7. Use of alternating street current 15

8. Use of continuous street current 16

9. Portable battery with amperemeter 17

10. Artery, treatment of 19

11. Artery, macroscopic appearance 21

12. Artery, macroscopic appearance 22

13. Artery, macroscopic appearance 22

14. Artery, microscopic appearance 24

15. Artery, microscopic appearance 24

16. Fallopian tube, macroscopic appearance 26

17. Fallopian tube, macroscopic appearance 27

18. Omental adhesions 31

19. Artery forceps 32

20. The dome 32

21. Visceral protection during treatment 33

22. Intestinal adhesion 34

23. Shield forceps for laparotomy 35

24. Small pedicle forceps for ovariotomy 35

25. Large pedicle forceps 36

26. Pedicle, treatment 37

27. Pedicle of fibroid, treatment 39

28. Sessile fibroid, incisions 40

29. Sessile fibroid, cuff of peritoneum 40

30. Dome controlling haemorrhages 41

31. Steps in treating stump in myomectomy 42

32. Treatment of broad ligament 43

33. Treatment of broad ligament 44

34. Final treatment of vessels 45

35. Use of dome in sac of Douglas 47

36. Removing tube and ovary 54

37. Removing tube and ovary 55

38. Seizure in appendectomy 61

39. Treatment of mesentery 62

X ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

NO. PAO»

40. Second seizure in appendectomy 63

41. Stump after appendectomy 63

42. Epithelioma of cervix 66

43. Epithelioma of cervix .... 66

44. Byrne's speculum 67

45. Byrne's speculum in position 68

46. Byrne's cautery loop 69

47. Byrne's special loop carrier 70

48. Passing loop around tumor 71

49. Diverging volsellum . . 72

50. Cautery knife 72

51. High amputation of cervix . . 73

52. High amputation of cervix . . 73

53. High amputation of cervix 74

54. Cervix excised 75

55. Dome electrode 75

56. High amputation of cervix 76

67. Stump after removal of cervix 77

58. Cautery incision in vagina 77

59. Elytrotomy 78

60. Hysterectomy, treating broad ligament 79

61. Diagram of seizures in hysterectomy 79

62. Shield forceps for vagina 80

63. Hysterectomy, treating broad ligament 80

64. Hysterectomy, treating ovary and tube 81

65. Peritoneal sutures 82

66. Peritoneal sutures tied 83

67. Pedunculated tumor of bladder 105

68. Protecting bladder wall 106

69. Treating urethral gland 116

70. Treating urethral gland 117

71. Hffimorrhoidal clamp 121

72. Operation for haemorrhoids 122

73. Operation for haemorrhoids 123

74. Dickinson's oblique seizure of haemorrhoids 124

75. Treating fissura in ano 127

76. Ordinary window frame 144

77. Improved window frame 145

78. Ordinary door frame 146

79. Improved door frame 147

80. Improved door frame with wood trimming 148

Plate I — Reorganization of stump facing 26

Plate II — Reorganization of stump 28 - '^

ELECTRO-H^MOSTASIS
IN OPERATIVE SURGERY

CHAPTER I

INTRODUCTION

In looking backward upon the evolution of surgical
haemostasis, one of the most agreeably surprising steps ob-
served in the progress toward the ideal is the discovery
that an aseptic ligature can be inclosed in the tissues with-
out disturbing the healing process. Catgut ligatures, prop-
erly prepared and sterilized, soon answered all the require-
ments of the surgeon in so many operations that he has
been disposed since then to rest satisfied in the belief that
the ideal method had been attained, so vastly superior was
the new way to the old. Even at the present time one is
liable to be considered hypercritical and fastidious if he
questions the utility and competence of the surgery of the
day in controlling haemorrhage in incised wounds. Never-
theless, the modem ligature has its defects and failings
when employed in certain operations and in some con-
ditions.

Some of those who first used catgut as a ligature ac-
knowledge that it is difficult to sterilize and keep perfectly
clean, and that it is not altogether reliable in ligating blood
vessels in the pedicle of an ovarian tumor, for example.
More recently it has been discovered that it is objection-
able in wounds which are septic or contain necrotic tissue.
Take, for example, a suppurating ovarian tumor or a pyo-
salpinx : the broad-ligament pedicle is nearly always sep-

2 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

tic, and no matter how clean the ligature may be when
applied it soon becomes contaminated by contact with the
diseased tissue, and, being dead animal tissue, it adds of its
own seK to the field for the culture of bacteria. A ligature
thus contaminated is not absorbed, but acts as a foreign
body for the promotion of evil and the interruption of the
process of repair, and is responsible for the bad results
which have sometimes followed when I had operated ac-
cording to all the rules of modern surgery. Others have
had similar failures from the same cause, if I may judge
from cases which have come to my notice. On this account
catgut is the worst material that can be left in a wound
which is not perfectly free from germs of disease. Of minor
importance, but still worthy of notice, is the fact that dry
catgut is not very flexible and easily handled, and if softened
by immersion in a sterilized or antiseptic solution it stretches
or breaks, and can not be depended upon to close vessels
and hold them. This tendency to stretch is increased by
the softening which takes place while the ligature is in the
tissues, and therefore haemorrhage may occur. This has
happened in abdominal operations, and on that account
many operators, even in the early days of modem surgery,
preferred silk ligatures for much of their work.

If I mistake not, the majority of surgeons at the pres-
ent time use silk ligatures in ovariotomy, hysterectomy, and
similar operations ; and yet the silk ligature does not meet
all the demands of surgery. The objectionable features of
silk are, that it is not absorbed but remains in the tissues
where it is placed, quiescent in many cases, but occasion-
ally causing much mischief. The unfavorable behavior of
the silk ligature has been so fully recognized by some of
the leading surgeons that they have raised the question
whether this non-absorbable ligature should ever be used
in abdominal surgery. Judging from my own limited ob-
servations and the meager records found in surgical litera-
ture on this subject, it appears that silk ligatures either
become encysted and remain where they are placed, or^

INTRODUCTION.

becoming freed from the protecting exudate, wander about
until tbey are thi-own out by the elimiiiative process of
suppurative or ulcei'ative inflammation.

Fine ligatures of silk applied to small blood vessels in
areolar and muscular tissue become walled in with repara-
tive exudates and may remain indefinitely, but those used
in abdominal operations are likely to work their way out
through the skin or eecajje into aome neighboidng viscus.
Under favorable circumstances the harmful action of silk
ligatures has escaped observation, owing to the fact that
they cause no trouble until long after recovery from the
operation in which they were employed. If the silk is
clean when used, no immediate disturbance of the process
of healing is caused, and so far silk appears to be a perfect
agent ; still, it is not so, for the neceasaiy \valling in of a
silk ligature requires more time than the disposal of an
absorbable ligature, and the quantity of new material left
in the wound suiTounding the ligatures retai^is the process
of repair. On this account the tissues in the neighborhood
of the wound remain indurated, and do not regain their
elasticity and freedom from tenderness for a long time, even
when uniim takes place promptly and without supjmration.

These facts regarfliug the slow i-eeoveiy or lepair caused
by the presence of silk in the tissue, and the disposition of
such ligatures to be thrown nut in course of time, are illus-
trated in an extirpation of themammary gland which occurred
in my practice. The patient being spare of habit and to a
slight degree hjemorrhagic, more ligatures were required than
usual, and all of the tine silk on hand mbh used uj), and so
one ligature of thick silk had to be used. Healing took
place without delay, but the tissues remained iudurated and
irregular, and iixed to the wall of the thorax for a long
time. There were also slight pains at times and tender-
ness. Two years afterwai'd the patient returned for advice
regarding an inflamed part about an inch in diameter, ])re-
senting all the signs of a small abscess, situated about an
inch and a half from the original incision. The parts were

4 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

incised and a mass of exudate or scar tissue removed with
a curette. In this mass I found the large ligature which
I had used in operating. The silk was in a state of good
preservation, and only the short ends of the ligature pro-
truded from the mass in which the ligature was imbedded.
The patient rapidly recovered, and there was no return of
the cancer one year and a half afterward. This shows
that the whole trouble came from the ligature and not
from the recurrence of the disease.

Were this all of the evil that can be charged fairly
against the silk ligature one might rest satisfied, but
worse follows the use of ligatures of all kinds in abdom-
inal and pelvic surgery. Ligatures applied to the broad-
ligament pedicles of ovarian tumors and Fallopian tubes
are guilty of much wrong-doing. For example, unless
the conditions are unusually favorable, the pedicle of
an ovarian tumor can not be tied tightly enough to close
the arteries in the way that surgeons say they should be
ligated to make sure of controlling haemorrhage with cer-
tainty. There is a liability, in thick pedicles, for the
tissues to shrink under the pressure of the ligature and
permit the vessels that have been temporarily closed to open
again and allow bleeding to take place. This inefficiency
of the silk ligature has been observed by Dr. Howard A.
Kelly, so that he has adopted the method of ligating the
pedicle in two sections, by including the ovarian arteries
in one ligature and the tubal and uterine side of the
pedicle in the other, and in addition to that he also ligates
the larger vessels in the end of the stump.

Whenever the tissues of the pedicle are rendered friable
by disease or degeneration, it is well-nigh impossible to con-
trol haemorrhage with a ligature of any kind. Silk is as
bad as or worse than anything else, for it cuts the tissues if
tied as tight as possible without breaking.

These are some of the charges which can be brought
fairly against the silk ligature as a means of immediately
and permanently arresting haemorrhage. The subsequent

INTRODUCTION. 5

behavior of the ligature, and the character of the stump to
be repaired after ligation, are still uiore unsatisfactory to
both the patient and the surgeon. The pressure of the
ligature upon the nerve tissue and the traction of the parts
towai-d the point of constriction, especially in a short,
broati pedicle, cause irritation and pain. There is a large
mass of tissue projecting beyond the ligature which has to
be disposed of by a process of degeneration and abst>rp-
tion ; the ligature and the tissue of the pedicle beneath it
have to be closed in by a deposit of plastic material, which
in time is disposed of by absoi'ption, and the ligature set
fi-ee. During all these weeks or months required to com-
pletely repair the stump there is oftentimes considerable
pain and distress in the site ; nothing dangerous or alai-m-
ing but annoying. Not infrei^uently when a diseased Fallo-
pian tube forms part of the pedicle there is a secondary
attack, maybe several, of inllammatiou in the stump, caused
by the tube remaining open and giving out septic material.
These sequel* have passed unnoticed by many surgeons,
and are lightly spoken of by others, presumably because
there was no danger to the life of such patients ; but the
best operatoi-s have given attention to the subject, and,
having watched their results with scientific accuracy, have
observed these results and recorded them.

What becomes of silk ligatures that are left in the
peritoneal cavity is a question of vast importance. One
opinion which for a long time prevailed was that a silk
ligature applied to a broad -ligament pe<licle becomes eu-
cyated and remains quiescent for all time. Exceptions to
this rule were admitted, and were accounted for by some
unclean operating or a septic ligature that caused suppui-a-
tive inflammation in the stump by which the ligature was
set free oi* found its way into some neighboring viscus.
This is almost altogether incorrect. Occasionally it may
happen that a ligature becomes finnly fixed to the bn)ad
ligament by an exudate and remains imbedded for aU time,
but that, I believe, is the exception, not the rule.

6 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

This very interesting question of the disposal of silk
ligatures, as a rule, has not yet been answered fully, so far
as I can ascertain. Guided by my own experience, I be-
lieve, as already stated, that ligatures left in the peritoneal
cavity are at first encysted and finally liberated, and remain
in the peritoneum or escape through some of the viscera or
the abdominal wall. So many cases of this kind have been
reported that I need say nothing on that subject, except
that they make their exits by being first set free from the
plastic stuff that surrounds them and travel outward by a
process of ulceration or suppuration and necrosis of the
tissues in the way of their outgoing. At least that is the
way of it according to my own observations.

By way of illustrating what has been said about liga-
tures being set free in the peritcmeal cavity, I give the
history of a specimen brought to my clinic at the New
York Post-Graduate School by Prof. F. Ferguson. The
patient from whom the specimen was obtained died of some
thoracic disease, and while making the autopsy Professor
Ferguson learned that she had had her ovaries and tubes
removed about one year prior to her death. The pelvic
organs were removed entire, and I had every facility for
their examination. The stumps were rounded off even
with the posterior surface of the broad ligaments, showing
that all that portion of the stumps outside of the ligature
had been disposed of, and also the exudate that had been
thrown around the ligatures to inclose them. The ends of
the tubes were open. The ligatures of thick silk were
found in the most dependent part of the sac of Douglas,
quite free from, but resting upon, the thickened peritoneum.
The thickening of the peritoneum in the sac resulted from
cellular proliferation and exudation, possibly brought about
by irritation arising from the presence of the ligatures.
What would have become of the ligature finally, if the
patient had lived, I know not.

From among a number of cases recorded in which the
ligature migrated I give the following: The patient had

INTRODUCTION. 7

, severe puerperal peiitcmitis followed by chronic ovaritis
and varicose veins of the broad ligaments. Tliia, with very
extensive old adlieaiona of all the pelvic organs, caused so
niuch aufEeriug that it became necessary to operate. The
tubes and ovaries were removed, the veins closed, and ad-
hesions separated. One ovary and tube were found high
up and held in this abnormal position by adhesions. When
these were ligated and lemoved the stump rested near the
lower part of the wound in the abdominal wall. The
recovery was quite favorable, but about two month.^ after
the patient was dismissed she returned, coaiplaiuiug of
pain in the sear near its lower end. The scar at that point
was stretched, and there was a slight pi-otrusion, not un-
like a beginning hernia, but there was some fluctxiation and
flatness on percussion, which led to a diagnosis of abscess.
An opening was made and a small amount of serum and
tissue dehrie escaped, but not any visible pus. The sinus
was washed out, but it would not close. A little serous dis-
charge continued for six weeks or two months, when she re-
turned ft)r treatment. Suspecting the presence of a ligature
that had escaped from its environing exudate, it was fished
out with a blunt hook, and then healing soon closed the sinus.
Having observed these disappointing actions of liga-
tures, I naturally looked for something better in sui^eal
hsemostasis. This I found in the work of Dr. Thomas Keith,
who taught me his method of treating the pedicle in ovari-
otomy by the clamp and cautery, which in theory and pi-ac-
tice was most satisfactory. No doubt this feature of his
operating contributed largely to making him the most suc-
cessful ovariotomist of his time. The experience of years
and a large number of operations in which his method was
used has fully confirmed my confidence in this way of
controlling hiemorrhage. The method of ti'eating the
jjedicle of ovarian tumoi-s employed by Keith and his
followers was never adopted by surgeons in general This
was due, apparently, in part, to ignorance of the principles
of the method, but moi'e especially to the ditticulties in the

8 BLBCTRO-HJSMOSTASIS IN OPERATIVE SURGERY.

technique of the procedure. Many believed, and still be-
lieve, that it was necessary to char the stump with the cau-
tery in order to stop the bleeding ; but the fact is, Keith
applied a clamp with broad jaws to the pedicle and com-
pressed it strongly, and then applied a large cautery iron
to the upper side of the clamp until the instrument \va8
heated sufficiently to desiccate the tissues and not to char
them. This required much time and large experience in
handling the cautery iron, in order to obtain the degree of
heat necessary and to know the length of time it should
be applied. In other woixls, to treat a broad-ligament
pedicle in this way required a knowledge and judgment
that but few had the patience to accjuire.

I confess that I was not sure of my work in my first
operations, and sometimes applied a light ligature to feel
safe before I dared return the stump into the abdominal
cavity. When ovariotomy became improved, so that better
results were obtained, and material for ligatures was made
aseptic and more appropriate, I gave up the clamp and
cautery and used the ligature ; but I was never satisfied
with the results, and earnestly sought to overcome the
objection to the clamp and heat to control hseinoiThage —
namely, the application of the heat supply. While think-
ing of how to overcome these difficulties, my attention was
called to the use of electricity in heating laundiy smoothing^
irons. It then occurred to me to adapt the same heating
power to surgical instruments, such as the clamp and f orceps*

My requirements in this regard were explained to Mr.
Louis M. Pignolet, an electrician, who has given much
attention to electricity as used in medicine and surgery.
He at once took up the study of the subject with enthu-
siasm, and soon produced the instruments and appliances re-
quired. He first made an artery forceps, then a clamj), and
finally a full set of ha3mostatic instiiiments. I should say
that it was his adaptation of the system of electric heating
to these instruments, which enabled me to employ the
method for the control of bleeding in all surgical operations.

CHAPTER II

DESCRTPnON OF INSTBCMENTS

The following description of the inatrumenta is given
by Ml-. Pignolet.

In these forceps the heat is generated by the passage
of an electric current through a resistance wire in a cham-
ber in one of the jaws, for it lias been found to be sufficient
to heat but one of them.

The method of heating ih simple, and is applicable to
forceps of various forms and sizes since the mechanism
of the instrument is not altered by the electrical attach-
ments. The constmction is shown by the illustrations, of

which Fig. 1 is a side view of a compression forceps heated
on this pi-inciple. Fig. 2 is a longitudinal section, ami Fig.
3 a top view of the heated jaw on an enlarged scale, with
the cover D and the insulating material f removed.

A resistance wire, A, is located at the bottom of the
chamber, close to the face of the jaw, fi'om which it is

10 ELECTRa-HJEMOSTASIS IN OPERATIVE SURGERY.

insulated by a thin layer, i?, of fireproof material. The
chamber above the wire is filled with an electrical insulator,
C^ which is also a non-conductor of heat, such as asbestos,
and is closed water-tight by the sheet-metal cover D. One
end of the resistance wire is connected to the jaw, and the
other to an insulated copper wire, E^ placed in a metal

tube, F. which extends
from the chamber to the

■Pw:v-«^-«N.-«.-vvv^^v.MLVvvvvv%^J>v^^^

<^-| ^-.v.>..v^.>v...^^^^^^^^^^ metal block, G, attached

^'^- ^- to the handle of the for-

ceps. Here the copper wire is connected to an insulated
terminal, H^ mounted in the block. A similar terminal, ly
is attached directly to the block and is uninsulated. By
this method of construction the electrical wires are incased
in metal, so that the forceps can be sterilized and handled
without injury, the same as an ordinary instrument. Start-
ing at the insulated terminal, the path of the cuiTent is
through the copper wire and the resistance wire to the
tip of the jaw, thence through the blade of the forceps
to the uninsulated terminal. The copper wire and the
blade of the forceps form a path of good electrical conduc-
tivity, and are consequently but very slightly heated by the
passage of the current used. On the other hand, the wire
in the chamber is a poor conductor, and is heated to a
greater or less degree according to its resistance and the
strength of the current.

The electrical energy required to heat the forceps varies
from ten to thirty-five watts, according to the size of the
instrument, and is less than that required by the ordinary
cautery electrodes. A
storage or primary bat-
tery that will heat the
electrodes will gener- ^ „

& Fig. 3.

ally answer for the

forceps ; but, as all batteries require care to keep them in
working order, the lise of the electric light or power cur-
rent from a dynamo is preferable wherever it is available.

\ WN^'VVV'.VN.XNNVV V\\'k,-'V><VvN.\SSN.\^sk<^ kVV.V'\VVvT \'s\'s"' \\SNkvk'\\'N\\\\^\^

.\ -S . ■ sS x\S

,_ii^N^^SV»\\>w\^\^

riESCRIPTION OP INSTRUMENTS. H

The dynamo cun-ent can be used through a controHiiig
rheostat, or, if the current be alternating, through a trans-
former cai)able of furuiehiiig a low voltage cniTeiit of vari-
ous Btreugths and presaui'cs to suit the different forceps.
A special advantage of the transformer is that the euri-ent
for use is of very low pressure, and is generated in an insu-
lated coil of wire by the inductive action of the dynamo
current which flows through an atljacent coil. If the wires
or connections be accidentally touched, nothing is felt on
account of the low pressure of the transfonner current, but
with a rheostat under similai* conditions a disagreeable
shock might be experienced. Furthermore, tlie insulation

between the two coils pi-events leakiige of the high-pressure
current to the low-pressure circuit, so that freedom from
shocks is insured. If the dynamo current be continuous,
the transformer can be used by converting the continuous
into an alternating current, by means of a small rotary
transformer.

An efficient and convenient tyj>e of transformer is repre-
8ente<l by Fig. 4. It will furnish cun'ent for heating the
forceps, and for all sizes of cautery electi-odes, as well as
for lighting small incandescent lamps. The pressure and
quantity of the current is increased by moving the switch

ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

arm to the right from one contact button to the next until
the proper amount is obtained. By noting the contact at
which the desired heat is developed for a particular for-
ceps, the switch may be set at that point, and the forceps
used with the certainty that the heat will be suitable.

As shown by Fig. 5, one end of the flexible cable for
conveying the electric current to the forceps is inclosed in

a soft -rubber tube,
and is provided with
two hollow metal
sleeves, Z K^ which
are mounted in a
piece of insulating
material, and are
adapted to slip over
the two terminals,
I H^ oi the forceps.
Each sleeve is insulated from the other, and is connected
with one of the two conductors composing the flexible
cable.

Fig. 5.

DIRECTIONS FOR USING THE ELECTRICAL FORCEPS.

The method of arresting haemorrhage with these for-
ceps consists in firmly compressing a portion of the bleed-
ing tissues or the end of a vessel between the jaws of the
instrument, in order to expel as much of the moisture as
possible, and then desiccating the compressed tissues by
heat generated in the jaws by the electric current. In
this way the walls of the arteries become united and
haemorrhage is effectually prevented. The temperature
required for desiccation is from 180° to 190° F., which is not
high enough to char or bum the tissues, but simply to
desiccate or cook them.

The forceps are sterilized in the same manner as the
ordinary instruments, but after removal from the sterilizer
it is not advisable to place them immediately into cold
water, while they are hot, as the contraction of the heated

DESCRIPTION Of INSTRUMENTS. 13

air inaide may eventually cause water to enter at the insQ-
lated terminals. After sterilizing, a little sterilized vaseline,
or similar prejjaration, ia rubbed over the inner faces of
the jawB of the forceps to cover them with a thin film,
which will prevent the tissues from adhering to the instru-
ment. The rubI>er-covered end of the electiical cable ia
sterilized in boiling water and afterwai-d wrapped in a
sterilized towel or immersed in an antiseptic solution — sucli
as a five-pei-cent carbolic solution — until needed. Bichlo-
ride of mercury should not be used, as it attacks the metal
sleeves at the end of the cable.

In applying the forceps, all the tissues to be treated
should be firmly compressed Ijetweeii the heated jaws of
the instrument, for if a ijortion extend beyond, a second
application will be necessary. Before the electric current
is turned on, a piece of gauze or a shield is applied where
needed between the forceps and the adjacent tissues to
protect them from injury by contact with the hot instm-
ment. Tissues which do not touch the Jaws require no
protection.

The two connector sleeves at the end of the flexible
cable are then slipi)ed over the two terminals on the end
of the forceps and pushed firmly into place to make a
good electrical connection. If the elective current has been
previously turned on, the putting of the connector sleeves
into place completes the circuit and establishes the cur-
rent ; but if this has not been done, the cuiTent is now
turned on.

The method of connecting the forceps to the liattery
or transformer, which may be useil as a source of electiicity,
is plainly shown by Figs, ii, 7, 8, and 9, so that no expla-
nation is needed. The current required to properly heat
the forceps is notetl for each one made. Therefore, it
can be regulated to suit the forceps from the indications
of an ampt;remeter included in the circuit to measure the
strength of the current. This is the best way ; but if no
amperemeter be convenient, ex[>eriments uiKtn a piece of

RLECTRO-nJEMOSTASlS TN OPERATIVE SURGERT.

mw meat will enable one to regulate tlie current to surt
the foreejjs, so that desiccation ia obtained in the proper
time. Expeiieuce will enable the operator to tell if the

^ temperature be right by touching the foitepa from time to
time; this can be done without pain as the heat is concen-
trated iiiKin the inner surfaces of the jawM, and the other
pai'ta of the instrument are not as hot. One setting of a.
transformer or of the rheostat of a storage battery will be
sufficient, if the same adjustment be made in subsequent
operations ; but the batterj' should not be used when its
chaise is nearly exhausted, if uniform results are desired,
unless an amperemeter be employed. For the same reason,
the transformer should be fed liy an electi'ic-light current,
as this has an almost constant pressure, and not by one

tused exclusively for power, as such a curi'ent is subject to
considerable changes of pressure. An amperemeter should
be used with the ordinaiy pnraary battery for the polariza-
tion, as the varying strength of the exciting fluid ])revents
it from being adjusted so as to furnish a cun-ent of uniform
strength.

Fig. B. — Forceps heatod liy tha electric current Iroiti b stDrage liatttry.

DESCRIPTION OF INSTRUMENTS. 15

Before removiug the forceps, the tissues projecting be-
yon(i its jaws are cut off, which niay in some cases be done
while the heat is being applied, in order to save time.
There being danger of losing sight of tlie stump by its
dropping back into the abdominal cavity, as for example
may happen in ovariotomy, the tissues on tlie under side
of the jaws should be grasijed by a shield or compression
forceps to hold the stump in place for inspection. The
electrical forceps is then carefully ojiened far enough to
allow the desiccated stimip to slide out from between the
jaws in the direction of the teeth. Care in thia is impor-
tant, for if the tissues should adhere to the instrument,
which may happen if vaseline be omitted, they might be
torn apart and a ragged stump be left.

socket on an ftlteniating electric -light dnniit, auJ hunting a forceps by the
low'prcssure current geoerated in its secondary.

Before UHing the forceps for the first time, it is instruct-
ive to experiment with them on a piece of raw meat, so
as to become familial' with their action, as well m to ascer-

16 ELECTRU-Il-iEMOSTASrs IN OPBIIATIVE .>^URGERT.

18 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

tain whether the source of electricity is suitable and can be
properly controlled.

Absence of bleeding upon the leraoval of the forceps
shows that the desiccation has been eflfective, and the
stump can be left without fear of secondaiy hsemor-
rhage. The occurrence of bleeding immediately upon
the removal of the forceps indicates that the desiccation
has been insufficient, or that some of the tissues have
escaped the grasp of the forceps. In this event, reap-
ply the forceps to the stump and repeat the heating,
giving about ten per cent more current, or continuing
the heat for a longer time if the bleeding has been due
to insufficient desiccation.

The time required for desiccation varies from a half
to two minutes, according to the thickness of the com-
pressed tissues or size of the arteries, two minutes being
required for the ordinary ovarian pedicle and the broad
ligament. If desired, or if the tissues be very thick, the
current can be continued for three or four minutes, or even
longer without danger, on account of the low temperature.
When the time of application has expired, the cuirent can
be shut off by a switch or by removing the connector from
the forceps. The desiccation can be hastened by starting
with more than the usual current, and continuing the
greater current for about a third of the time of applica-
tion. Fox' example, if the current necessary to properly
heat the forceps is ten amperes and the time of applica-
tion is two minutes, give twelve amperes for about forty-
seconds, then decrease to ten amperes for the rest of the
time. It is well to commence with the forceps closed
on the first notch of the lock, and after the heat has
been applied for about half a minute and the tissues
have begun to shrink to close the instrument fully. In
this way the greatest possible compression of tissues is
obtained.

In the treatment of isolated arteries the end of the
vessel is grasped by a tenaculum, and the electric artery

DKSCBIPTION OF INOTRUMENTH. 19

forceps applied crosswise, or the artery is seized by the
e!e(!ti'ic foi-cepa in the same manner as with an oi-diuary
artery forceps when a ligature is to be used. Isolated
ai'teries, or those inclosed in a mass of tissue, when treated
by this method are so thoroughly and completely closed
that they can not be opened up again either by blood
pressure or the most critjcal dissection. This has been
clearly observed and fully demonstrated both clinically and
by laboratory experiments.

The end of an artery or the stump of a pedicle when
thus treated resembles parchment in gross appearance.
The thickness depends upon the size of the \'essel or mass
of tissue treated. A large uterine artery is reduced to
about a line in thickness, and an or-
dinaiy broad-ligament pedicle to less I
than an eighth of an inch in thickness. I
See Fig. 10. The part is translucent
and structm-eless, and thus enables the I
surgeon to tell at a glance when the I
treatment is incomplete, by obsei'ving \^^ ^^_^^ ^^,^^^ j^_^
the vessels that remain unclosed ; he frtshheofeioseiiBdiidly
knows then that the pressure and heat half a minute. Seen in
should be reapplied to complete the [l^'^^'tiresU^^ '"'""
hiemostasis.

Occasionally in treating a thick mass of tissue the
central portion of it becomes heated before being fully com-
pressed, and the blootl is coagulated in the vessels and leaves
dark strips or general staining of the' tissues, which causes
some o])acity in the parts. As a rule, however, the blood
is pressed out of the vessels before the desiccating begins,
and the stump is sufficiently translucent to enable the
operator to see any vessel that has escai>ed. The indica-
tions or requirements for closing vessels are in this way
thoroughly fulfilled by the complete fusing together of the
walls of the vessels so that they do not, in fact can not,
come apart. This I have demonstrated again and again.
While I found in my fii-st observations that the hsemostasis

20 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

was immediately complete, I was suspicious that when the
tissue became softened by absorbing moisture the vessels
might open up and subsequent bleeding might return, but
many clinical experiences and experiments settled that
question beyond all doubt.

CHAPTER ni

RESULTS OF THIS HEMOSTATIC PROCESS

To my clinical observations I have the satisfaction and
pleasure of adding an experiment made by Dr. K. L.
Dickinson. He placed a mass of tissue, one pait of which
was treated by this method, into non-sterilized water and

Fto. 11.— ^.untreated end; B,d-

let it remain immersed for about seventy-two bom's. At
the end of that time the tissue not ti-eated was a soft pulpy
mass tliat bnike down under presaure of the fingere ; while
the desiccated poilnon remained firm, though somewhat
softened by the water, but with no separation of its c<tra-
ponent parts, neither could he find any part where cleavage

22 ELECTRO-ILEMOSTASIS IN OPERATIVE SURGERY.

or dissection could be made. I have repeated this experi-
meot many tunes witii the same reeulta

Fio, 13. — Section through A, Pig 11 a, endothelial cells (intima); 6, subendo-
thelial layer (intiinti) ; c, internal elastic membrane (intima); d, media; «,
adventitia; /, lumen of artery

RESULTS OF THIS H-EMOSTATIC PROCESS. 23

Finally, I may state that I have employed this method
in over two hundred abdominal ojierationft, and in many
vaginal hyaterectomies and other opei-ations, and have
never had secondary haemorrhage in any of them.

These are the facts regarding the method as an hsemo-
static. There still i-eniains the question of the subsequent
behaviors of the ends of the vessels and the tissue thus
treated — in other wonk, the process of repair.

Fi-om all the facts that I could gather on this subject
in actual pi'actice, I concluded that the desiccated tissue
became first hydrated and theu reorganized, and remained
as permanent structure, closing for all time the ends of the
blood-vessels, lymphatics, and canals so treated. There
was still an uncei-tainty on this point, until Dr. W. H.
Seymour, the pathologist to my department in the college,
conducted a series of independent experiments in the
Hoagland Laboratory. The account of these observations
and experiments by Dr. Seymour and the illnstrationa
made under his supervision are as follows :

In the first place, the doctor observed that an artery
a quarter of an inch in diameter wm reduced to about a
twelfth of an inch in thickness (see Figs. 11, 12, 13), and
that the structure of the tissues was rendered amorphous by
the heat anil pressure. The lumen of the artery was oblit-
erated completely, so that m> trace of its original structure
couhl be found. (See Figs. 14, 15.) A piece of tissue, con-
taining arteries, nerves, fibrous, muscular, and ai'eolar tissue,
Mas treated in the same way and presentetl the same amor-
phous appearance and complete closure of the arteries. So
completely fused together were the walls of the lumen of
the arteries that no trace of the original structui'e could be
fimud, neither could the lumen be reopened l)y teasing the
microscopic specimen.

Observations were made of sections of the Fallopian
tubes, ap[)endix vermiforrais, ureters, and other canals
lined with mucous membrane, and the same amorphous con-
ditions were found. The sti-ueture of the mucous mem-

24 KLECTKO-H^MOSTASIS IN OPKHATIVK SURRERY.

brane was so completely changed that no part of itH original
structure couUI be found by niicniscopical examination.

Fia. IQ (umier higii powiir).—

RESULTS OP THIS HiUMOSTATIC PROCESS. 25

The thoroughness of the closure of the ailenes was
demousti'ated by attaching a fountain syringe to the opening
of the artery and using double the ordinary blood pressure
without opening the closed end of the vessel.

The advantages that may be fairly claimed for this way
of controlling bleeding in sui^ery are, that it is certain and
reliable in closing isolate<l vessels or those imbedded in
masses of tissue, like an ovarian-tumor pedicle for example.
At the same time that bleeding is arrested, all lymphatics
are sealed up, which i>revents septic absorption. The
tissues of the stump are reduced to the smallest possible
size, and there are no raw surfaces left to foira adhesions
to the abdominal or pelvic viscera, nor any foi-eign sub-
stance left in the tissues to cause mischief, advantages that
can hardly be overestimated.

Tissues which have become fiiable by disease and can
not withstand sufficient pressure of a ligature to control
bleeding are easily managed by this method. When the
tissues that form the pedicle of a suppurating ovarian cys-
toma or a pyosalj)inx contain septic germs, a condition in
which the ligature is most objectionable, a better and much
safer stump can be made in this way. A ligature used
when the tissues are in this condition, especially a catgut
one, is very objectionable, for the dead animal tissue of
such a ligature forms a perfect medium for the development
of disease germs. It is also the only way that canals lined
with mucous membrane — the Fallopian tube and the apjien-
dix vermiformis, for example — can be permanently closed.
Tills \\i\\ he refeiTed to when discussing special operations.

Nerves that accompany the vessels are immediately de-
vitalized, and hence there is less pain and in-itation in the
stump. The heat employed sterilizes the parts involved,
and therefore the operation is perfectly aseptic. To these
many advantages may be added that it leaves the stmnp
of a pedicle or the end of an artery in a condition re-
quiriiii^ the least reparatory care, so that I'ecovery is more
prompt, uneventful, and complete.

ELECTHO-li.KMOSTASIS IN OPERATIVE SUIiaKUY.

Miicrowopif mill Microectfpic Appearances of the Falhpiun Tulm
irealed wUh the Elect t'o-lHi-inoelaiie Foroepit.

These cibservstions buvo Imuii made uii two tilunips, taken from usniiie subjrats,

Bt the onil iif the third siiil lutith dny of Ihe healing iirocesa. following In^iHrolniiiy.

In each instance, prinr to ihp aiiplicatinri nf thn f"i<'i'|i«, cHri'riil nnMsPiilip

e followed out in tho fxpnsun; of ilie lubi' :un\ iiii'nis, Th.' liBuno-

F](i. Ill represents tlie

prnr

. llif end i)t Die third day of the healing

at&tic forceps of tlio smallest size wns plnesd on ench stump for one miiiiite, and
an electrle current used of sufficient strength to raise the temperature of the for-
eepB to 180°.

MiCttoacopio Appearance {Pig, 1(1). — The forceps was placed about half an inoh
fmm the l)i furcation of the uterus on the Fallopian tube, broad ligament, and blood-
vessels. At the point of application is noted a can strict, ion corresponding in width
to the cautery clamp, on the surface of whiuh are niimeroua cornijnitions which
correspond to the same in 1)ie blades of the instrument. A decided eomprewioa
is shown to exist at the point of application, nnd also a quantitj' of recent lymph

ELECTRO-IKEMOSTASIS IN UPEIIATIVE SURUEUY.

Mavfoaciipic and Microscopic Appearances of the Fallopian Tube.
treated uUh the Electro-ho'moatalic Forceps.

Those observations have been made on two stumps, taken from canine subjects,

at the onil of the third and tenth day of the healing prowss, folloiring laparotomy.

In each instnuc. prinr to the appliivntinn nf the furci'pn, t'lircful nnliseptii-

opposite: 1^

TUBE V

'^^

I^^^^P -■■>- TUBC

€t

Fju. Ifi represents tlie lubr rtinoved at the enJ of the third day of the healing

static forceps of the smallest si/e was placed on each stump for one minute, and
an electric current used of saffieient strength to raise the temperature of the for-
ceps to 180°.

Macrobpopic Appbakance fPig. 10). — The forceps was placed aliout halt an inch
from the bifurcation of the uterus on the Fallopian tube, broad ligament, and blood-
vessels. At the point of application ia noted a constriction corresponding in width
to the cautery clamp, on the surface of which are numerous corrugatioi
correspond to the same in the blades of the instmment. . A decided con
ia shown to exist at the point of application, and also a quantity of recent

in width

ipression H
it lymph H

RESULTS OP TDIS HEMOSTATIC PROCESS.

and Bolid exudate found over tlia tree end of tho stump. Considerablis pcoliy-
motio hmraprrhage ia noticed at the uterine end of the area treated witli tliu hu'iiio-
Blatie foreepH, The free end of the tube is seeu to be softened, nod I'orrusprjndf
iti appearance with what might be expected in the earlier stages of uoiiguhitiori

1 uf the lumezitil portion, mauroscopically, the canid is seen
to be obliterated.

Microscopic AppeabiINCK [Piute I, Fig. 1, Icirigitudiiial aettioii). — Uinler the low
power (Plate I, Fig. 2) the mucosa and aubmucosa ace everywhere inflUroted with
ecu uti ess small round cells; the blood-vessels are obliterated, their lumena being
CMDiripressfld. The free edges of the mucous membrane are seen to be in apposition,
uo distinct line of demarcation (Inmenal) being apparent. Considerable softening
exists in Ihe outer portious of the wall of the oviduot. The siuall round cells
can, with little difficulty, be traced far back into the muscular layers of the organ.

Under tlie high power (Plate I, Fig. 8) are seen countless small round cells of
the reparative process, intermingling witli which are also fine fibrous elements sur-
rounding Hinall and large areas of coagulation necrosis. On studying the lumenal
portion of the mucous inembi'ane the small round cells of one surface seem io
merge or blend with those of the upposite, thus preventing the recognition of the
lumenal margin of the mucous membrane.

Micaoscopic Appearance (Fig. 17). — The tube resembled, in its treated portion,
that of the third-day specimen, the treated area, however, being ranch duller in

FiCr. 17 represents the tube

outline, firmer over its end, and containing much less softened malerial and lymph
than in the former specimen. The lumen can iiot be niacrosonpioally identifled.

Microscopic Appkaeancb.— A section wbh made of a portion of the oviduct
through the lumeu and mucosa, longitudinally, at the point of application of the

ELECTKO-n^MOSTASrS IN OPEltATlVE SURGERY.

RESULTS OF THIS HEMOSTATIC PROCESS. 29

haBmostatic forceps. The duller portion represents marked areas of coagulation
necrosis, together with some haemorrhage by diapedesis, shown in adjacent neigh-
borhoods.

The mucosae of the two walls of the tube are seen to be in contact, thus produc-
ing actual obliteration of the lumen of the tube due to active proliferation of the
cells of the mucosa and infiltration of small round cells.

Plate II, Fig. 1, represents one of the areas of coagulation necrosis in the more
superficial portion of the mucous membrane. Plate II, Fig. 2, represents a smaller
area more highly magnified, showing countless small round cells from infiltration
processes.

CHAPTER IV

ELECTRO-HJEMOSTA8I8 IN OVARIOTOMY

The part of this work relating to the management of
hsBmoirhage in abdominal and pelvic surgery is of necessity
fragmentary, as it treats of hsemostasis in this class of oper-
ations only. In describing this method of arresting the
haemorrhage which occurs when making the abdominal
section, separating adhesions, and treating the pedicle in
ovariotomy, I shall follow the steps of the operation in the
order in which they have just been named.

The hcemorrhage in abdominal section comes mostly
from the vessels of the skin, and should be arrested if at
all free before dividing the deeper structures. The vessels
should be seized with the artery haemostatic forceps and
heated under pressure until they are closed. The method
of treating small vessels in incised wounds is fully de-
scribed under the head of extirpation of the mammary
gland, which will be described in a later chapter. If the in-
cision in the deeper structures of the abdominal wall is
made in the median line, as it should be, and the large
veins that are sometimes found in the peritoneum are
avoided, no important haemorrhage occurs. The advan-
tages of treating bleeding vessels in this part of the oper-
ation are that no ligatures are left in the wound, and the
injury of tissue caused by twisting the arteries or bruising
them with compression forceps is avoided, and therefore
the tissues are left in a better condition to heal promptly.
It is my opinion that this is a very important factor
guarding against subsequent ventral hernia.

l,K(:Tlto-n,l';MosTAnis IN ovariotomy.

K of the (mientum to the cyst wall or tumor are
treated by making traction upon the cyst wall to biing it
and the adherent jKirtion of the omentum out of the ab-
dominal wound. A narrow-bladed forceps ia applied to
the omentum, close to the cyst wall, and the portion in tlie
graap of the foreeps heated under pressure until fully
desiccated. The portion thus treated is divided near to
the cyst wall but in the line of desiccation. See Fig. 18,
whicL shows a part that has been treated and divide<l, and
another portion in the grasp of the forceps. In cases hav-
ing a large portion of the omentum sui-face attached the
adherent part can not be bn)Ught out of a small-Hized

wound far enough to reach the free portion to be separated.
In such conditions the incision should be enlarged suffi-
ciently to facilitate the operator's manipulations partially
within the abdominal cavity. Great care is necessary in
such cases to protect the intestines from the heat while the
forceps is being used. Fortunately such adhesions are very
rare. Tlie omentum lieing thin and the vessels small, only
about twenty to thirty seconds are required to close them.
In rare cases, when the omentum is thickened by inflam-
mation, and the vessels very much enlarged, a minute of the
heat may be re(^uired.

32 electro-ii.*:mostasis in operative surgery.

Adhesions of the Appendix Verm iform is. — The api>endix
is found adherent in pyosalpinx quite frequently, and is
discussed in connection with that subject. Suffice it to say
here that when the appendix is adherent to an ovarian

tumor it should be
removed with the
tumor.

Fig. 19.-Artery forceps. Th® method of

removing the appen-
dix is given in the chapter on appendectomy.

The raw, bleeding surfaces left after separation of ad-
hesions to the wall of the abdomen, deep down in the sac
of Douglas or elsewhere, are treated first by seizing the
largest bleeding vessels with the arterj^ forceps (see Fig.
21) and closing them. Then the oozing from the very
small vessels is stopped by using the dome-shaped instru-
ment. (See Fig. 35.) This is slowly passed over the sur-
faces until all oozing ceases.

The operator must guard against letting the intestines,
uterus, or bladder come into contact with the dome instru-
ment when it is in use. With ordinary care the needed
protection can be assured by having the patient in the
Trendelenburg position and keeping the abdominal and
pelvic viscera out of harm's way with sponges and retractors,
as illustrated in Fig. 21.

The technique is exceedingly simple, and the results
most satisfactory compared with the old way of ligating
the larger vessels (always a most difficult thing to do) and
using persulphate of iron or hot water to stop the oozing.

Fig. 20.— The dome.

In fact I never was able to arrest bleeding and oozing com-
pletely and quickly, and make the parts clean and dry in
pelvic surgery of this kind until I devised this method of
operating.

ELBCTRO-H^MOSTASiS IN OVARIOTOMy. 33

Tntestinal adhesions are managed by making gentle
traction and stretching the adhesion so that the forceps
can be placed between the cyst wall and the intestines.
While the pressure and heat are being applied, the shield
forceps should be placed on the side toward the intestines
to protect them. When this is impossible, owing to close
and extensive atlhesionH, the intestine is dissected away

Fm. 21. — Protecting the titorus from the forceps.

I from the cyst in such a manner as to leave a portion of the
external coat of the cyst wall on the side of the intestine.
These flaps are bmught together over the raw surface of
the intestine and seized with the forceps, compressed and
desiccated. (See Fig. 23.)
In doing this the shield forceps should be used to keep

("ntO-Ii,K.M()STASIS IS <H>KltATIVK SUKCiEKY.

i-csciiiblcH nil ofdiiiiiry coiiipi-i'ssinn f<tiv('i>s, Iiiit lias tliin,
flat Hhieldw iiintcad of jaws, m hIuhvii by Fij^. 23. Tlie
shields are constructed of thin blades of steel coated with
a substance which is a jtoor e<iiiductor of heat, such as
hard rubber, and are hmjrcr atid broader than the jaws of
the elwtricul forceps. One side of each sliiehl is flat and
the other is beveled, as sliown, so that the inside edges are
chisel shaped. Tlie flat sides uiv phice<l ui)j)enuost, close
af^iinst the electrical instmnieiit. When i)roperly placed,
the shield foiteps is locked with surticient pressure to re-

l''iii. 22. — Tiio trcHlmont nf iiilwliiiul jtilliesioTis.

tain the desiccated stump for inspection after the other
instrument is removed.

AiHii-hIoh'^ to the n-viitm (the most difficult of all to
niatiage) are treated in the same way as intestinal adhesions,
with this diffei-ence, that when the adhesions ai-e veiT
strons;, and the cyst wall chantred in structure by inflam-
mation, a i>ai-t- of the cyst wall shoulcl lie left attached and
its ]iiiiii<; membrane destroyed with the dome cauteiy.

AiJh'-xiuiiH of tlie lihiihh-f to the tumor are treated by
dissectin<j ofl: tile bladder an<l then closing the j)eritoneum

ELECT liO-Il^KMOSTASIS IN OVAIUOTOMY. 35

over the bladder with fine catgut sutures. Adhesiona that
ai-e recent, not very extensive, and easily separated, are
treated by tnuehing the i-aw surface with the dome cautery

Fio. 33.— Shield toToeps.

at a temperature of 180°, to arrest any tinzing that may
take place.

The Pedk'le. — The cyst eac or turaor being withdrawn
from the abdominal cavity the pedicle is examined with
regard to its length and thickness, to determine the point
at which it should be divided, and the size of forceps or
clamp required for its treatment. Small and medium-sized
pedicles call for the smallest pedicle forceps, illustrated by
Fig. 24, and constructed as follows ; The instrument is
jointed at the distal end by a detachable lock, and has a
projection on either blade at the pi'oximal end of the jaws,
which prevents the tissues fiom spreading when the forc^eps

18 closed. Tlie handles lock with the usual catch near the
proximal end. Larger pedicles require the clamp forceps,
illustrated by Fig. 25, and constructed in the. same man-

30 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

ner as the small pedicle forceps, but having a movable
section which can be closed by a screw attachment. By
this means the pressure is made parallel to the heated jaw,
and a greater and more e<|ual compression is thereby ob-

FiG. 25^ — Clamp forceps for larger pedicles.

tained. The forceps selected is applied at the point where
the pedicle is to be divided. One or two fixation forceps
are applied to the base of the tumor, and the pedicle
divided between them and the haeniostatic clamp, leaving
a portion of the pedicle projecting above the blades of the
clamp to prevent slipping. This portion should be cut off
close to the forceps just before removing it. The shield
forceps is applied beneath the haemostatic forceps to pro-
tect the abdominal wall from the heat, and to keep the
stump from falling back into the pelvic cavity when the
haemostatic forceps is removed. (See Fig. 26.) This
enables the operator to inspect the stump and see if it has
been properly treated before it is dropped. If any portion
of the stump, or the whole of it, indeed, is not fully
desiccated, the forceps can be reapplied and the treatment
completed.

Sterilized vaseline should be applied to the inner surface
of the blades of the forceps, to prevent the stump from
adhering and to permit the forceps to come off easily. The
forceps should be closed only to the first notch in the catch,
and when the current has been turned on and used for about
half a minute the compression should be completed by clos-
ing the forceps to the last notch. During the time that the
electric current is being used the operator should examine

ELECT liO-^H.KMOSTASIS IS OVARIOTOMY. 37

the other ovaiy and the other pelvic organs to see if any-
thing more in the way of operating is required.

An unusually short, thick, broa*l pedicle, that can not
be accommodated in the largest clamp forceps, should be
treated in three aections. The outer border, ^vhich con-
tains the ovarian vessels, should be grasped with the for-
ceps used for vaginal hysterectomy, treated in the usual
way, and divided; the inner boi-der should be treated in
the same way ; the middle portion, or third section of the
pedicle, if not vascular may be cut off without treatment,

and the edires of the peritoneum of the stump closed with
fine sutures. If the middle part is vascular it should be
caught in the pedicle clamp and treated like the other
sections.

38 KLKCTliO-II.KMOSTASiS IN OPKRATIVK rtUllGKllY.

For one who \h not familiar with thiH treatment of the
{)e<licle it in diiiiciilt to tell when the treatment in Htiiiicient
to be reliable. TIuh waH to me a mont diiiicult queHtion
in my firHt operationH, liiit I H<H)n Iearne<l that if there wan
no <liH[M>Hition to bleeding when the clamp waH removed, it
could surely be trusted.

DID II nuraber of successful myomectomies in pedun-
culated tiliroids, a,iid iu all I foimd difficulty in cuntrol
ling the bleeding with the ligature. Such was my
perieuce that I never dared to remove a Beseile subj^ri-
toneal fibroid until I olitained the hemostatic forceps.
Siiu-f then I have siR'cc(.'dc<l equally well »itli ;il] f<.

of pedii

dmwn oatwsrd. ami t

of subperitoneal fibroids. The methotl of operating when
the pedicle is long enough is to apply the forcei>s iu the
same way as it is used upon tlie pedicle of an ovai-ian
tumor, compress and desiccate it, and then cut away the
tumor.

40 ELECTRO-n^MOSTASIS IN OPERATIVE SURQEUy.

When tiie pedicle is short and the fibroid is in contact
with and yet movable upon the middle coat of the utenne
wall, the 0!ii>mile is <livided all around on the tumor one to
"twL. iuclifs tVditi thi; utcniw. It is (ht'ii ilissfcted off with

the dry diisseetar until the tumor is enucleated; the empty-
portion of the capsule is finally gathered together and
grasped in the forceps and desiccated by the electric heat.
(See Fig. 27.)

The shield forceps is used to protect the uterus from
the heat. The redundant part of the stump which pro-
jects beyond the blades of the forceps should be cut clean-
ly off after the treatment is completed, and before the for-
ceps is removed.

Sessile fibromata are treated in the same way, excepting

Fio. 30. — Sessile fibroid enucleated. Showing entt of pertton

that when the attachment of the tumor to the uterus is
quite broad the incision of the capsule should be made
higher up on the tumor — that is to say, it should be nearly
as high as the diameter of the base of the tumor (Fig, 28).

MYOMECTOMY AND ABDOMINAL HYSTEltliCTOMY. 41

When the incision is made, and enougli of the cajwule has
been freed from tlie tumor to get hold of, onlinary com-
pression forceps should be used to control bleeding until
the enucleation is completed (Fig. 29). The two sides of
the capsule should be held apart while the surface of the
uterus from which the tumor was detaclied is carefully in-

F:o. 30. — The uso of tlie donio in trealinp; blPucHng raw surface aftor enucleation
.ifsossily liljroid.

speeted, and all oozing stopped b}' the application of the
dome cautery mentioned in the description of ovariotomy
(Fig. 30). The flaps of the capsule should be brought
together, grasjied by the forceps, compressed and desiccated
, 31). This completely aiTests all hseraon-hage, and

ELECTRO-II^MOSTASIS IN OPERATIVE SURGERY.

leaves the smallest possible stump. Occasionally several
small subperitoneal fibroids accompany one or more large
ones. These little ones are quickly disposed of by making
an incision through the capsule at the summit of the tumor

PAVI SURFACE \^^l t OTl t^"^

Fio. 31. — Stops in treating stump after enucleation of sessile fibroid.

with the cautery knife, and enucleating and treating the
sac or capsule as already described.

ABDOMINAL HYSTERECTOMY FOR FIBROMATA

The abdominal incision is made long enough to permit
lifting both the uterus and the tumor out of the abdominal
cavity. The body of the uterus is drawn toward the
left side, and the right side of the abdominal wall is re-
tracted, so that the right broad ligament is fully exposed.
A com})ression forceps is applied to the upper part of the
broad ligament, including the ovarian arteiy, near the brim
of the pelvis. Another forceps is applied opposite the
first one, near the uterus. The round ligament is caught
in a forceps in the same way and the ligament divided
down to near the uterine artery. The lower part of the
ligament is opened up and the uterine artery found and
caught in a compression forceps. If the artery can not be
separated from the tissues of the ligament without much
trouble, the ligament and artery may be seized en masse.
The uterus is separated from the bladder, and the cervix
uteri divided or amputated in the usual way. The uterus
is tilted still farther to the left side to bring up the
lower portion of the broad ligament and left uterine ar-
tery. This also is seized by compression forceps and the

MYOMECTOMY AND ABDOMINAL HYSTEItKLTOMY. 43

ligament divided from below iipwaitl, Foicepa are applied
to the round ligament and the ovaiiHii artery when they
are approached iu the protiees of (Uvidinfj the ligament. Fig.
32 shows the line of incision, and Fig. 33 shows the exsec-
tion of the uterus and the temjjoraiy couti-ol of the ai-teiies
with coniiiression forcejis.

The tumor having been thus removed, the treatment of
the vessels is accomplished as follows : The divided end
of the artery is caught up with a tine dissecting force]>s and
drawn out of the tissues of the ligament and seized with
tiie hsemostatic forceps, compressed and desiccated. Wlien
it liapiieus that the broad ligament has been divided close
up to the compression forceps, the artery can not be iso-

■Treatraeiit of right broad liganiunt and temporary control of vpswls.

lated sufficiently without taking off the forceps; but if the
end of the artery is grasped witli the dissecting forcei)s the
tissues can be sti-ipped back from the artery far enough to
admit the gi-asp of the hemostatic forceps. Fig, 34 shows

4-1 EI,ECTllO-II^MOSTA.SIS IN OI'EKATIVE SUItOERY.

tlie ovarian ai-tei-y after it has been closed, and also the
uterine artery in process of being closed or treated.

I was fearful that the pressure of the forcepH tijion the
broad ligament if continued for any great length of time

Il3»

Pio. J)3. — TreatLnunt of left lirnail lijtdtiieiit Bnd l.emponirj' control of vessels.

miglit HO bruise the tisHues that sloughing would take place,
and the process of repair be thereby retai'ded. So 1 treated
eauli arteiy as it was divided — that is, tlie compression for-
ceps was ai>i)Hed lightly, and the artery and ligament di-
vided and immediately closetl with the haemostatic forceps.
Ihen the other arteries were treated in the same way. Ex-
perience, ho^vever, indicates that unless the compression of
the tissues is greater than necessary, the damage done is

MTOMErTOSlY AND ABDOMINAL HYSTERECTOMY. 45

not sufficient to retard repair ; the circulation is re-estab-
lished, and healing goes on rapidly.

The peritoneum is closed over the broad ligaments and
stump of the cervix uteri ^vith running catgut sutures.
Beginning above on the left, one suture is intixiduced al()ng
t<i the center of the cervix, the other suture is applied from
above downward on the right side until it meets the suture
of the left side, and the two are secured by tying their ends
together.

fbrrcpf in Ihe act

Fib. 34. — Final treatment of vessiels.

When it is necessary to remove the entire uterus, the
exsection of the cervix is added to the operation above
descrilwd. There are two ways of doing this : eircunifising
the vagina fi-om below, or opening and detaching it fixim
above. Certain advant^es belong to both ways of oj^emt-
ing in certain couditions ; therefore the surgeon should
select the method adapted to the conditions in cases as
they come.

46 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

When the cervix is within reach from the vagina, it is
easier to circumcise the cervix uteri through the vagina,
and the lower portion of the bladder can be more easily
and safely separated from the uterus in this way than
through the pelvic cavity from above. The disadvantages
of tliis method are, that it increases the time of operating,
especially when the vaginal wall is vascular, since time is
required to stop the bleeding before opening the abdomen.
But when the cervix uteri is drawn up out of, or crowded
to one side of, the pelvis, it is better to separate the cervix
and vaginal wall from above.

The method of operating which I have adopted saves
time enough to make it preferable, in my judgment, in suit*
able cases.

Two incisions in the vaginal wall, one in front and one
behind the cervix, are made, so that they meet on either
side of the cervix ; the bladder is separated from the uterus
up to the peritoneum, the vagina is separated from the pos-
terior wall of the cervix, but the peritoneum is not opened.
By this procedure the lower portions of the broad ligaments
are exposed. The haemostatic forceps used in vaginal hys-
terectomy is applied to the lower portion of one ligament,
which is compressed and desiccated, and ^cut off from the
supravaginal portion of the cervix. The other side is
treated in the same way. This frees the cervix from all of
its attachments, except the peritoneum, and at the same
time arrests all bleeding from the vessels which supply the
vagina. This part of the operation is performed precisely
as the first steps in vaginal hysterectomy. The abdominal
part of the operation is performed as already described,
except that in place of amputating at the cervix, the peri-
toneum in front and behind the cervix uteri is opened
toward the incision made from the vagina.

It is sometimes found that when the uterine artery is
ligated and the ligament divided down to the part sepa-
rated from the vagina there is a branch of the uterine or
vaginal artery that bleeds ; this is easily controlled by using

MYOMKCTOMY AND AHDOMINAL IIYSTEKEOTUMy.

the lisemoatrttic forceps. The dome in very useful in arrest-
ing capillary oozing in the deep locations hardly accessible
by other mesins. (See Fig. 35.) The peritoueum is closed
over the bi-oad ligaineute iu the way already described, and
the vagina is closed by iutermpted suture, including the
peritoueum aud vaginal walls.

The reader will observe that I liave adopted Kelly's
method of doing this operation, only slightly modifying it

Fro. 3.',.— Tlic U'^v ->f ihc Wni,„.a,.,.|. in the ciil-t
Tile pHtiPTit. is in Mio Tii'niii^li'ninirg posluri
The trcaLed stiinipa tit tlie vcsijelo aro shnnii , .

Ortery of roimd llBftment. ; E, compressed ami heated stump o( u'
A, posterior, and I), ntiterior peritnnenl flap.

to suit the new method <tf controlling the bleeding vessels.
Dr, Kelly, in describing his method of doing abdominal
hysterectomy, adds some valuable remarks regarding its
advantages in complications, which I (]uote here:

" I have insisted particularly upon the novel way in
which serious complications are simplified by this jdan of
treatment, and I would refer chiefly to two kinds of com-
plications :

48 electro-h^:mostasis in operative surgery.

" First, fibroid tumors located under the peritoneum of
the pelvic floor ; and,

" Second, inflammatory masses situated behind the broad
ligaments, with dense adhesions to the pelvic peritoneum, to
the rectum, and often to the small intestines.

" In the case of the subperitoneal pelvic fibroids, it is
astonishing how difficult they are to get at from above, and
how easily, on the other hand, they roll out when handled
from beneath by this procedure.

" I would say the same of the inflammatory cases.
Matted masses, adherent in all directions, which resist
enucleation from above, are often removed with ease w^hen
rolled up from the pelvic floor from below. The adherent
structures seem to be unrolled in a natural and easy way,
in surprising contrast to the difficulties experienced and the
injuries inflicted in gaining the slightest fingerhold in pro-
ceeding from above.

" To recapitulate : Abdominal hysterectomy by the con-
tinuous incision down through one broad ligament, across
the cervix and up through the other broad ligament, is con-
trasted with hysterectomy by an incision down to the cer-
vix through one broad ligament, and then down through
the other, followed by amputation of the cervix.

" The special advantages offered by this method of
operating are :

" 1. The saving of from sixty to eighty per cent of time
in the enucleating stage of operation.

" 2. The ease with which intraligamentary myomata
and myomata beneath the pelvic peritoneum may be enu-
cleated.

" 3. The ease with which inflammatory masses pos-
terior to the broad ligament may be enucleated by attack-
ing them from below after dividing the cervix.

" 4. The control of a displaced ureter on the side last
opened up, keeping it out of the way of injuiy by the sim-
ple mechanism of the operation."

CHAPTER VI

EI-EOTRO-H^MOSTASIS IN OVABIO-SALPINGECTOMT

Ai.TiioiJGn tlie mortality in operationH for pyosalpins
and kindred diseases of the tubes and ovaries has been
reduced to a minimum, there has been such a large per-
centage of incomjilete recoveries that some of the lJes^
known sui^eous have expressed dissatisfaction with the
ultimate results. During my investigation of this class of
uncured cases, I found that ligation of the i)edicle had been
practiced in all of them, and that all kinds of ligatures
had been used, while in those treated with the cautery
clamp, according to Keith's method, no such results fol-
lowed. Those who recovered after that treatment were
l)ennanently relieved. I naturally inferred from this that
the ligation was the cause of the unfortunate effects', and
in one sense that is the case. In explanation I must say
that while the ligature itself is the cause of some trouble,
the worst afflictions come from patency of the Fallo]>ian
tubes, which remains after treatment >>y ligation.

Professor Eniil Hies, of Chicago, has given (see Amen-
can Gynaecological and Obstetric Journal, January, 1898)
the unfavorable results following the removal of the tul>es
and ovaries, and the causes thereof, in a most infeivsting
and valuable essay, from which I have taken the following.
After noticing that Schauta and Chro>)ak rejwrt but little
more than fifty per cent of their laparotomy patients as
really cured, Dr. Ries suggested that one of the most im-
portant causes of these unsatisfactory I'esults was to be
foimd in the fomiatitju of stump exudate.-, and offers a new

50 ELECTRO-II^KMOSTASIS IN OPERATIVE SURGERY.

explanation of this cause in the following observation of
several eases in which niicroscoincal examinations were
made of the uteri removed some time after sali)ing^ctomy.

" Stump exudates were found by Schauta in twenty-
eight cases out of his one hundred and seventy-two sal-
pingo-oOphorectomies. They have been found even more
frequently by other observers, and in my own experience I
have repeatedly found them to be at the bottom of trouble-
some symptoms months after the operation. They produce
pain, sometimes so severe that the patient is unable to
attend to her work ; in some cases the pain is even worse
than it was before the operation. The exudates are found
around the 8tumi)s of the removed tubes, and vary in size
from a barely palpable thickening of the uterine horn to
the size of a hen's egg or larger.

" As an explanation of the formation of these tumors,
Schauta offered the following two possibilities :

"1. The inflammatory process creeps on through the
uterine wall into the surrounding parametric and perimetric
tissue ; and,

" 2. Germs were present in the broad ligament at the
time of the operation (though no actual observations could
be offered as evidence of this), the connective tissue of the
broad ligament was laid bare by the operation, and in this
way the germs could invade the peritoneum.

"Though these observations did not meet with any
opposition, it can not be overlooked that we have no obser-
vations bearing out the correctness of these hypotheses.
Besides, I can not help feeling that they are very artificial.

" The cases are as follows :

"Case I. — Mrs. J., twenty-four years old. Seven
months previously a left pus tube and ovary had been
removed. A sinus remained which would not close. Be-
sides, the patient has an ovarian abscess the size of a fist,
and hydrosalpinx on the right side. Uteinis adherent all
over, forming part of the wall of the sinus. I operated
September 28, 1896. Laparotomy. Removal of ovarian

. • «. • • •- •- *'*'♦'

ELECTRO-H^MOSTASIS IN OVARIO-SALPINGECTOMY. 51

abscess, hydrosalpinx, uterus ; excision of sinus, which leads
toward the right cristum ilii and terminates in an abscess
which contains five silk ligatures. Recovery.

" The stump of the tube which had been removed seven
months previously is excised, and examined in a series of
sections, embracing the entire stiunp up to the interstitial
portion of the tube. The cavity is open throughout. The
epithelium is the usual low columnar epithelium of this
portion of the tube, and stops at the surface of the stump
without investing the cut surface of the stump. No threads
to be found in the stump.

"Case II. — ^Miss W., twenty-five years old. Several
years ago removal of both tubes and right ovary. Now
chronic pelviperitonitis and adherent retroflexion. Opera-
tion by Dr. W. H. Rumpf, on December 8, 1896. Vaginal
hysterectomy.

" Both tubal stumps are examined in series. They are
perfectly permeable^ though the cavity is very narrow.
Epithelium well preserved up to the abdominal opening of
the stump. Besides, the left tube contains some epithelial
ducts outside the circular muscular layer of the tube, one
of which enters the circular muscular layer itself, but does
not show any communication with the tubal cavity (remnant
of the WolflSan body). No threads to be found in the
stump."

At a meeting of the American Gynaecological Society,
held in Boston, June 26, 1898, Dr. J. Wesley Bovee, of
Washington, D. C, read a paper on Patency of the Stump
after Salpingectomy, in which he said that he had taken
a special interest in this subject since 1892, and had found
in five specimens from cases of salpingectomy that the
stumps were still pervious. So far as he knew, only three
well-authenticated cases had previously been reported.
As I remember the reading of the doctor's paper, he ac-
counted for the patency by saying that the ligatures might
become infected and slip in course of time, or '^ mass "
ligatures might slip off after closure of the abdomen. He

52 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

suggested that these stumps might be successfully occluded
by cutting out the Fallopian tube by a wedge-shaped in-
cision into the uterine wall at the tubo-uterine junction,
and closing the wound with sutures. Care must be taken,
he said, in the ligation of the uterine artery in this situa-
tion, and also not to pass the sutures through the mu-
cosa.

It appears that Dr. Bovee was not acquainted with the
work of others when his paper was prepared, but he de-
serves credit for suggesting a way of overcoming the paten-
cy of the tube which so often follows the use of the liga-
ture, and for adding five more to the list of unsuccessful
cases following the usual method of operating. This
method suggested by Dr. Bovee may be an improvement
upon the old way of operating. Still, it requires longer
time to introduce sutures than to use a ligature, and if the
end of the tube is septic the wound in the uterus is sure to
become contaminated and so complicate the process of re-
pair that trouble may follow. At any rate I am quite con-
fident that better results are obtained more easily by the
method which I have adopted.

The operation for the removal of the tubes and ovaries
should be adapted to the pathological conditions presented
in given cases, simple and complicated.

The incision into the abdominal wall should be short,
just sufficient to admit two fingers. Extra care is necessary
to avoid wounding the omentum or bowels. If there are
adhesions of the intestines to the abdominal wall, the in-
cision should be enlarged in order to find a part where the
peritoneum can be safely opened, and from which the adhe-
sions can be treated. This is easier than to separate the in-
testines from the peritoneum in the incision. This complica-
tion is, fortunately, seldom met. I have occasionally found
the omentum adherent to the tube and ovary, and some-
times to the abdominal wall near the median line ; but it is
generally free on one or both sides, so that the tubes and
ovaries can be reached by passing the fingers outward be-

ELECTRO-n^MOSTASIS IN OVARIO-SALPISGECTOMY. 53

yond the ailheaious on the side, and then drawing and
pualiiDg the omentum out of the way. When no free part
can be found, the omentum should be picked up and
divided in or near the median line, and the bleeding ves-
Bels closed with tlie hfemostatic forceps. Two fingers
should be passed into the wound and the fundus uteri
found. This is a guide to the tubes. Adhesions, wlien
they are not too old and strong, should be separated with
the fingers, but care must be exercised not to rupture the
tube. When both tube and ovary are freed from adhesions,
they shuuki be hooked up with the fingers and brought out
through the wound, or up into it. By traction in this way
a pedicle is formed, included, and held between the fingers
until the hfemostatic forceps is applied, the shield forceps
a<lju8ted, and the pedicle treatfd in the way described
under the bead of Ovariotomy for Ovarian Cystoinata.
(See page 37.)

One sometimes finds the pedicle too short to permit the
tube and ovary to be drawn out of the wound far enough
to apply the forceps outside of the abdominal wall. In
that state of affairs the hseinostatic force])8 is ajiplied under
the fingers in the abdominal incision, the distal end diji-
ping down into the cavity. The shield forceps is applied
from the same side as the hsemoatatic forceps, and a retrac-
tor is used to keep the side of the abdominal wall and intes-
tines away from the point of the forceps while the heat is
being applied.

Cutting away the tumor or tube and ovary is always
a serious matter, owing to the tendency of the septic con-
tents to escape and contaminate the stuniji and "Oimd ;
to some extent this is always the case when the ligature
is used. The desired object is accomplished by not mak-
ing traction upon the jiarts to be removed while the heat
is being applied. When the ])edicle is thoroughly desic-
cated the part to be excised joining the forceps becomes
dosed by the heat wuftioiently to prevent leaking after being
■divided. With a sharp knife the jwrts are cut close to the

54 ELECTRO-U^MOSTASIS IN OPERATIVE SURGERY.

forceps, while care is taken not to make pressure on the
tube and force out its contents.

In pyosalpinx complicated by firm and extensive ad-
hesions the operation is altogether different. The outer
ends of the tube and ovary are freed from adhesions until
the ovarian artery is reached and that portion of the broad
ligament caught in the forceps, closed with pressure and
heat and divided. This liberates the tube and ovary so
that they can be brought out through the wound (in case
the adhesions of the tube are not very firm), and the
uterine end of the tube and the remaining portion of the

Fia, 36.— Removal ol diseased tube and ovary by the forceps. Partly diagi^i

mesosalpinx can be grasped with the hysterectomy forceps
or hemostatic clamp, sealed up, and the tube and ovary cut
away. (See Figs. 36 and 37.)

If the tube is distended close up to the uterus and the

ELECTRO-H^MOSTASIS IN OVARIO-SALPINGECTOMY. 55

adhesions are extensive, the operation has to be modified
still more. After closing the ovarian artery and dividing
that portion of the pedicle, the ends of the tube and ovaiy
are dropped back, and the forceps having been applied to

the tube close up to the uterus, they are thoroughly com-
pressed and desiccated, and then divided in the line of the
closed portion of the tube, A traction forceps is applied
to the end of the tube to keep it from falling back into
the pelvic cavity. The separation of the adhesions is com-
pleted and the tube and ovary brought out of the wound,
and the remaining pedicle — ^that is, the mesosalpinx — treated
in the usual way with a small haemostatic forceps. If the
adhesions are old and vascular there in generally some
oozing from the raw surface of the broad ligament, and
this should be 8toj>ped by passing the dome cautery
heated to 185° or 190° over the oozing surfaces until they
are dry.

If the tubes are largely distended and their walls ai"e
thin, the adhesions should be separated only where that

56 ELECTRO-H-SMOSTASIS IN OPERATIVE SURGERY.

can be easily done ; the tubes are emptied, or partially so,
with the aspirator, and then seized with the forceps and
brought out. The adhesions should be separated by divid-
ing them with scissors, or, if veiy vascular, the haemostatic
forceps should be useil. The pedicle is then treated in
one mass or in three sections as last described.

When lx>th tubes and ovaries are diseased, especially in
double pyosalpinx, the uterus should also be removed.
The operation is then performeil in exactly the same way as
abdominal hysterectomy for uterine fibromata.

CHAPTER VII

ELEOTRO-H^MOSTASIS IN APPENDECTOMY

Finding that the treatment of the pedicle of ovarian
tumors with compression and heat applied with the electric
cuirent gave infinitely the best results, I employed the
same method in appendectomy with equally fortunate and
gratifjang success.

That the same secondary troubles followed append-
ectomy as after removal of the Fallopian tube was appar-
ent on reading the records of many surgeons. A. Lapthorn
Smith says that he had several cases from one to two years
after the appendix had been removed, who were suffering
from fecal fistula or pericaecal abscess. This is about the
same as the testimony of Armstrong also, who reported in
the British Medical Journal, October 9, 1897, that fecal
fistula followed fifteen times in five hundred and forty-one
cases. A. Lapthorn Smith very clearly states that " because
of the mucous glands which are imbedded in the mucous
membrane of the appendix, it is (juite as unsurgical to put
a ligature aixnind the base of the appendix a (juarter of an
inch from the caecum and then cut the appendix off, as to
propose to close an opening in the bowel by jncking up
the edges of the oj^ning and tpng a ligature aiound them,
because this would simply bring mucous surfaces into con-
tact aud. when the lisratui-e has cut throufifh or lia.s other-
wise fallen off, the secreting glandular surface w<»uld sepa-
rate and the contents of the l>»wel escai>e. Those wlio
follow this methoil mav Siiv that thev cauterize the nuic* ais
membrane after cutting off the aju^endix, and not only

68 ELECTRO-UiEMOSTASIS IN OPERATIVE SURGERY.

disinfect it but also destroy its secreting surface. But
this, I maintain, it is impossible for them to do, because they
manifestly can not reach the mucous membrane brought
together by the ligature, and still less that part of it which
lies below the ligature. If there were only one case of
fecal fistula instead of fifteen in five hundred it would be
worth while preventing it.

" The ideal method, in my opinion, and which I have
followed in these cases, is for an assistant to hold up the
intestine an inch on one side of the appendix, and, after
tying and cutting the meso-appendix, to snip the appendix
off even with the caecum. The hole in the intestine is
then sewed up with fine silk, care being taken to include
the nmscular coat. A director is then pressed upon the
line of the suture until it sinks below the surrounding
surface, when another row of sutures brings the peritoneal
surfaces together. Such a closure will almost surely unite
by primary union, doing away with all danger of fecal
fistula or circumcsecal inflammation, by which the opening
in the appendix is sometimes closed, and in which cases,
although there is no fecal fistula, the patient is subjected
to a good deal of discomfort while Nature is throwing out
a layer of plastic lymph to seal the defective closure.
Some authors recommend the peeling off of the peritoneal
coat of the appendix, so as to form a cuff a quarter of an
inch long, and then, after tying and cutting off the appen-
dix in the manner which is condemned above, make up
for the defect by sewing the peritoneum over the end of
the stump. This is much better than leaving a slough-
ing stump free in the 'abdomen, but it is by no means as
good as the method advocated above, in which no stump
at all is left, and nothing but a fine, thin line of Lembert
suture, which we know gives absolutely no trouble."

This same method, described above, was fully given by
Haggard, of Nashville, in a paper reported in the Trans-
actions of the Southern Surgical and Gynaecological Asso-
ciation, at the tenth annual meeting in St. Louis, last

ELECTBO-Il^OMOSTASIS IN APPENUKCTOMY. 59

' November. He summed up its merits an follows: "Total
excision of the appendix, with closure of the hole iu the
head of the colon, was said to do away with the following
dangers; (1) Subsequent perforation of the stump under
the ligature from infection in its own cavity ; (2) abscess
of the wall of the cascnm from invagination of the infected
I stump; (t'J) continuance of the infected process from stric-
' ture in the stump between distal ligature and the proximal
opening of the apjtendix into the csecum; (4) imperfect
invagination, with the incomplete drainage of tlie stump,
on account of the ciecal wall being thickened and stiffened
with inttanunatory exudate."

I have uot had an opj)ortunity of examining, post

mortem, the stump treated with the hieniostatic forceijs,

but have observed clinically that during the reparative

process no immediate exudation can be detected ; neither

I have there been any remote inflammations or exudates found

I on examination that caused pain or any other symptoms.

\ The recovery has Iwen complete and permanent. This is

as might be expected, from the fact that the lumen of both

, the tubes and the blood-vessels is completely obliterated

I by compression and heat, and does not, in fact can not,

I reopen. That complete disorganizatitm of the mucous

I membrane of tubes or vessels and permanent closure of

I their lumen are affected has been demonstrated in the

I several experiments detailed in the third chapter of this

I work.

This experience in ovariotomy and kindred operations
^ led me to expect equally satisfactory results in append-
ectomy, and my expectations liave beerj fully realized in
practice. In fact, this iiiethtMl of treatiii<( the stumji of the
appendix has special a*lvantages in being the only satisfac-
I tory way of controlling hiemorrhage in softened septic tis-
sues, as well as cliwing the ap])endix itself.

In salpingectomy, ovariotomy, and a]>pendectoniy the

I BUi^eon often finils that the pedicle or point of sejfaration

s diseased, and the ligature is likely to cut the tissues if

60 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

made tight enough to close the vessels ; and even if that
mishap is avoided the stump is infiltrated with septic ma-
terial, which causes trouble no matter how sterile or asep-
tic the ligature may be. With the haemostatic forceps the
vessels and lumen of the tube or appendix, as the case may
be, are completely closed and the stump thoroughly disin-
fected at the same time. I have had abundant opportuni-
ties to prove the advantages of this method of controlling
bleeding vessels in pelvic surgery. I am now using it in
other branches of surgery with equally satisfactory results.

The following case history is given as reported by a
clinical assistant :

W. S. P., aged thirty-two years; a New York mer-
chant, of medium build, active disposition, neuro-sanguine
temperament, regular habits ; primary assimilation and ulti-
mate nutrition good. Physical examination reveals appar-
ently perfect health. Complaint is made for the past
month of a dull ache in the right iliac region, usually
merely annoying, but at times severely lancinating and
markedly distressing. There are no other symptoms, either
gastric or intestinal, except that the bowel is inclined to
constipation.

A physical examination was easily made because of the
laxity of the abdominal wall, and revealed a small movable
tumor in the region of the appendix.

The patient's condition does not prevent his continu-
ance in the regular duties of his business ; yet, in view of a
history of six other attacks, he seeks relief from the pain
and mental disquiet by operative procedure.

The patient enjoyed good health until two years ago
last Fall. The first attack was provoked, apparently, by
a bath immediately after dinner. The local symptoms
were typical of an inflammatory condition of the appendix
vermiformis. The pain at first was general over the abdo-
men, beginning in the epigastrium, but soon became local-
ized in the right iliac fossa. After four or five days of
rest and medication relief was obtained, and the regular

ELECTKO-n^MOSTASIS IN APPENDECTOMY. 61

busineBS duties were resumed. In Febinary, 1896, wliile
sufferiug fi'om a severe cold, a second attack prostrated the
patient. At this time the pain was at once localized in
the region of the appendix, and recovery under treatment
was retarded for nearly two weeks. Again, in May, 1896,
after paitaking heartily of lobster, the patient was seized in
a similar manner for the third time. On this occasion his
condition was deemed m critical that he was advised to
submit to an immediate operation. After nine or ten

days, however, he was relieved by medical treatment, and
in a short while was able to attend to liis business duties.
Six months later, Thanksgiving Day, 1896, an extended
railroad trip was suddenly intermitted by a fourth attack
similar to the prece<ling ones. This was followed by a
fifth in Febraary, 1897, and a sixth in May of the same

■ fifth in Fe
H year.

■ The att

The attacks were all similar in their onset, nature, and

62 BLBCTEO-£La:MOSTASIS IN OPERATIVE SURGERY.

course. The pain came suddenly, without any premonitory
symptoms, and after the first time it was at once localized
in the region of the appendix; there was no gastric dis-
turbance except a slight nausea, nor intestinal, except
tympanites; relief followed the exhibition of opium and
local hot compresses. At the present time of comparative
quiescence, and while he is yet in first-class condition to
bear an operation, the patient has at last consented to the
repeatedly advised surgical interference.

The operation was done Janu-
ary 11, 1898. For the first time
m -tJ^^M in the history of appendectomy the

^^ iK^f method of operating with the elec-

^B ^IKl *"" hsBmostatic forceps was fol-

^1 ^h/ lowed. This departure from the

^m ^^Km current methods of ligature, su-

^h ^^^^M ture, cauterization, invagination, and

^^vV^^^H^ others is the logical outcome of the
^ ■^^CB success of this practice when operat-

yj*^, ing upon the pelvic viscera. All

f « ^^^ the other steps of the operation

y^J'X/ were such as are advised by sur-

Y-'^i^r geons generally. The incision was

— ■AkL the ordinary one over McBumey's

^^^^p point, two inches in length. On in-

Pio 38.-Oornpieted treatment gpection, both the appendix and the

of raesentery in appendec- ^ ' -"^^

tomy. The scissors have bi- meso-appendix were found to be
a seizure. much enlarged and thickened, and

superficially traveled by numerous dilated blood-vessels.
There were no adhesions. The first gi-asp of the forceps
was upon the meso-appendix close to its mesenteric at-
tachment. (See Fig. 38.) A current which heated the
forceps to 180° F. was then induced for half a minute.
Upon removal of the forceps the tissues were found to be
not charred but dried, having the appearance of white
homy matter. Scissors were used to bisect this desiccated
area. (See Fig. 39.) A second seizure was made upon

BLECTRO-H^MOSTASIS IN APPENDECTOMY. 63

r the appendix itself close to the caput coli, and the same
1 current continued for ninety seconds. The forceps was

Fro. 40. — Second seizure uf forceps in nppendeptomy;. The dried surface of the
first seizure has been bieecled. The appendix is grasped. The shield SoT'
ceps are shown faintly.

then removed and the tissue divided in the line of the
desiccated area away from the caput. (See Figs. 40 and
41.) The same result was mani-
fested. No charred tissue, no
bleeding, and, more important than
all, no escape of the contents of
the appendix. The tissues had
simply been dried out. Just at
this point a rather violent attack
of retching came upon the pa-
tient, which continued for nearly
a minute, yet without inducing
I any change whatever in the

Btump. All the severe pressure Fic. 41.— stump after appendec-

^ and strain had not forced even tomy.showingihetwo=*izures.
a speck of blood or serum into the compressed area.
The abdominal cavity was left perfectly free from any

64 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

foreign matter whatever. Sutures and dressings as usuaL
Time of operation fifteen minutes.

Anaesthetic, Schleich solution No. 3, nine drachms. Time
for induction of narcosis, seven minutes.

The specimen measures seventy-five millimetres in length
and forty-five millimetres in circumference, and is of an
irregular S shape. The contents were about a drachm of
pus, mucus, and broken-down cellular tissue. The meso-
appendix is also much thickened, even to ten millimetres,
and its greatest width is twenty millimetres.

A microscopic section made shortly after the operation,
according to the Johns Hopkins " fifteen-minute " method,
confirmed the diagnosis by revealing the typical structure
of an old recurrent hypertrophied inflammatory change.

The convalescence has been unmarked by any compli-
cations due to the operation. When the sutures were
removed after a week the parietal wound was perfectly dry
and clean. At the close of another week the patient was
sitting up, enjoying his newspaper and cigar, and was dis-
charged from our care on the seventeenth day. He was
seen eight months after the operation, and reported that
his health had been perfect, and that he had had no pain
or tenderness in the region of the operation.

I do not expect the judicious, cautious surgeon to
accept the history of this one case as evidence of the
superiority of this method to others that have been tried
more fully ; but my experience with it gives me full con-
fidence that the verdict rendered by a full and fair trial
will be favorable in the highest degree.

CHAPTER VIII

TREATMENT OF CANCER OF THE UTERUS BY THE ELECTRO-
CAUTERY AND HiEMOSTASIS

During the past few years the treatraest of cancer of
the uterus has been vaginal hysterectomy almost exclu-
sively, and upon theoretical grounds that appears to be
the most appropriate way of dealing with this disease.
Yet a careful comparison of all methods practiced leads to
the conclusion that other methods of operative treatment
are called for in certain conditions and give better results
than any one operation.

The unprejudiced observer who has read the writings
of Dr. John Byrne, and has seen his work and the results
in amputation of the cervix uteri with the galvano-cautery,
will be convinced that this practice is worthy of the sur-
geon's confidence. In very recent times, that is in 1895,
Dr. Kelly and Dr. Clark reported a more radical method
of abdominal hysterectomy for cancer, which, judging from
their subsequent results, also merits attention and appears to
meet the requirements in advanced cases of cancer of the
uterus.

In my own practice at the present time I choose the
operation best adapted to the stage, location, or condition
of the disease in question. The condition or character of
the disease and its location presents several forms.

In the majority of cases the disease begins in the cervix.
In some the tissues around the os externum are first in-
volved and the new tissue o-rows downward into the
vagina. Fig. 42 illustrates this stage, in which only the

(56 ELEOTRO-H^MOSTASla IN OPERATIVE SURGERY.

lower or vaginal portion of the cervix is involved. In
other cases the disease begins in the mucous membrane

within the cervical canal and dilates the cervix extensively
before it jmitnides into the vagina. (See Fig. 43.) A con-

dition which resembles this is that in which the diseaise
begins in the lower part f)f the cervix and extends upward

THKATMENT OP CANUEK OF TilE UTERUS. 07

into the cervix while the portion that protruded into the
vagina has sloughed oft". In rare cases the disease begins
in the body, or fundus iitert. In the iiret condition de-
scribed amputation with the galvanocautery ecraseur is
called for. In the next state high amputation is required
with the cautery kuife. In the last condition mentioned,
cancer in the coipus uteri, hysterectomy is the only opera-
tion indicated. These operations I shall describe in the
oilier named.

Amputation of the Cervix Uteri with thf. Oaleano-cautery Ecraseur.
Dr. John Byrne having been the first to operate suc-
cessfully with the galvano-cautery and continuing to be the

Fid. 44. — Bjrne'a speculum (or vagiuul lijsterectomy.

highest authority on the subject, I shall give Iiis descrip-
tion of the ojiei'ation. First, in regard to the ex{H)Sure of
the part to lie amputated, Dr. Byrne uses his own sjiecu-
lum, which he descriijes as follows: "The instrument i-e-
feiTed to is the speculum introduced and described by me
about fifteen months ago, and a modification of which is
here shown (Fig. 44).

"This speculum, it u-ill be obseiTed, differs none in
principle from that (previously noticed ; and as to the sev-
eral pieces of which it is comixised, they may be considered
the same, with one exception — namely, the frame on which
the lower or perineal blade moves is much wider and a
little longer, thereby affording more working space and

(18 ELECTUn-lLI'lMnSTASlS IN OPPIRATIVE SL'BGERY.

greatly facilitutiiig operative manipulations. Tlie fore-
shortened view in tbe above aketeli will nerve to explain
more clearly the points of difference between this 'o()erat-
ing ' and tlie ordinary speculum,

"Some advantages, however, will be found by Iiaving
the intravagiiial parts of thin insti-ntnent a little longer —
say half an inch — and from one (juarter to three eighths
wider than the ordinary wize. I have alwo occawionally re-
sorted to a iiiece of lietil. wnririt,' wii'c, t" lir iiitr'odiiccd iiffci'

the Bpecnluni has been mijusted and the uterus fixed in
position, for the purpose of still further separating the
lateral walls. This, though l)y no means an indispensable
requisite in any case, may nevertheless be made to render
good service, under certain circumstances, and on this ac-
count I have given directions to have some such device
supplied with each 'operating' speculum.

"Fig. 45 is intendetl to represent more clearly the prin-
ciples on which this speculum is constructed and the modus

TREATMENT OF CANCER OP THE UTERUS. 69

operandi by which the curved vagina] canal is not merely
dilated but straightened by pressing back the perineum
Itelow, while the vesical Avail is elevated above. The under
blade, it will be noticed, is made to move iu a circle in
which the center is indicated by its point, so that the rela-
tions of the latter to the cul-de-sac, when the instrument is
first introduced, does not materially change, no matter to
what extent the i^erineal blade may be pressed backward.
The various directions, too, in which the upper double rod
may be made to move is a most important feature in the
instrument ; for, however displaced a uterus may be, more
especially if anteverted, and provided no firm adhesions
exist, there is no difficulty in bringing it into view, and so
fixing it for examination or treatment.

" Fig, 46 represents an improved loop instiuraent."
In operating for epithelioma of the cervix uteri charac-
terized by exuberant outgrowths from a base, Dr. Byrne
places the patient upon the back, exposes the cervix with
his speculum and applies the platina wire loop as high up
in the cervix as possible, and made moderately tight, the
heat is applied and little or no contiaction of the loop being
affected for a few seconds, so that the tissues to be cut may
be thoroughly cauterized.

Traction by the cautery instrament should, in all cases,
be carefully avoided and the instrument kept steady and in

itery loop.

the same position from the beginning to the end of the oper-
ation.

The loop should be slowly and very modei-ately tight-
ened just enough to follow up the tissues as they are divided
by the cautery heat. When the tissues ai'e firm enough to

YO ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

stand traction, the part to be cut off should be seized with
a forceps and traction made continuously while the amputa-
tion is going on. This leaves a dome- or cup-shaped stump,
thereby removing the central tissues higher up.

When the portion of the cervix is conical and the cautery
loop is difficult to apply, Dr. Byrne has employed the fol-
lowing ingenious method of operating, which I have taken
from one of his histories of an operation :

" A large-sized rubber crochet needle, rounded at the
end, was heated and slightly bent so as to accommodate
itself to the curve of the sacrum and posterior contour of
the tumor.

" A small hole was drilled transversely near its distal
extremity, and at right angles with the direction of its
curve, and through which a stout platina wire was passed

Fig. 47. — Byrne's special loop carrier.

half its length. The free ends of the wdre were now passed
through two copper tubes, each three sixteenths of an inch
in diameter and eight inches long, and bent nearly the
same as the rubber rod, Fig. 47.

"An anaesthetic having been administered, and the
patient placed on her left side, the two tubes with the
rubber rod between were carried behind the tumor as far up
as deemed safe. The rubber support being now intrusted
to an assistant, and maintained steadily in position, one of
the copper tubes was carried around half the circumference
of the tumor, the wire being pushed up, piece by piece,
from below, and, when the center anteriorly had been
reached, was so held until the opposite half had been en-
circled in like manner. Two small pieces of wood, each
one-inch copper conductors, were one after the other slipped
up so as to unite, yet insulate the latter.

TREATMENT OF CANfER OF THE UTERUS. 71

" This being accomplished, the free ends of the platina

wire were next passed through a modification uf the looj
Dstrument as shown in Fig. 48 and the copper conductora
irmly fastened in the socket. All being now in readiness
he battery connections were made, when the heated wire

cut through the rul)ber support and imbedded itself in the

substance of the tumor.

"The rubber rod waa now withdrawn, and the looj

very slowly contracted, the time occupied in cutting througl
;he whole mass being fully thirty minutes, exclusive o:

^H^^£^!^

I'jii. A'^.- -Mi'lliv.ii of passing hiu\i tiTOiind liiiiii^r.

necessary iiitfiTiii>tioHs. There was no liji'moi'i'luige fi'im
;be stump, but the vagina was tamponed as a precautionary
measure."

HIGH AMPt-TATlON

In conditions admitting of high amputation, the follow
ng is the method usually resorted to : The uteruH is to be
exposed and the vaginal walla pnitected in the mannei
already described. The diverging volsellum (Fig. 49)
after being passed well into the cervical canal, should no«
>e expanded to a proj^er degree and locked, so as to affon
complete control of the uterus duiing the entire operation
s

72 ELECTRO-II^MOSTASIS IN OPERATIVE SURGERY.

By alternate traction and upward pressure of the uterus,
an accurate idea may now be obtained as to the proper
point to begin the circular incision, so as to avoid injuring
the bladder or opening into the cul-de-sac of Douglas. As
to the latter, however, should it be found that the disease
has involved the retro-uterine tissues, and that its excision
or destruction by the cautery can not be effected without

Fig. 49. — Diverging volsellum.

opening into the peritoneal cavity, there need be no hesita-
tion in doing so. I have never known any harm to come
from it whether it was done accidentally or by design.
Should it be evident at the outset that the operation, in
order to be thorough, must include a portion of the cul-de-
sac, it will be better to make the line of incision anterior to
this, until the cervix has been removed, and leave the inci-
sion of the retro-uterine parts hy the cautery hnife to be the
final proceeding. Under these circumstances all that will
be needed will be an antiseptic tampon properly applied.

In proceeding to make the
circular incision the cautery
knife (Fig. 50), slightly curved
a/nd cohl^ should be applied close

''"'• 'fl:;u,:vedifuL7a.'""" "P ^ *^« ^agi^^l junction, and

from the moment that the cur-
rent is turned on, should be kept in contact with the parts
being incised (Figs. 51 and 52).

Before removing the electrode for any purpose, such as
change of position, or altering the curve of the knife, the
current should first be stopped and the instrument again
placed into position while cool before resuming the incision.
In other words, if the Jcnife, though heated only to a dull red^

THKATMENT OF CANCER OF THE UTERUS.

>Ued to parts at all vmcular, hcBmon-hage mote or leas

I wiU certainly follow ; whereas, the cool platdnwm blade being

. 51. — First step in high imputation of cervix. Making the circular incision.

I in contact with moisture as the cwrrent is being trans-
l into Jieat, vessels are shimnlcen or closed even befoi'e
they are severed.

Tliis is 11 very imjrortant point aud should never be lost
sight of in all cautery operatious.

74 BLECTRO-IIJEMOSTASIS IN OPERATIVE SURGERY.

The circular incision having been made to the depth, say,
of a quarter of an inch, it will now be observed that by in-
creased traction the uterus may be drawn much farther
downward, and by directing the knife upward and inward
the amputation may be carried to any desired extent (Fig. 63).

In cases calling for amputation above the os internum,
it will be better to excise and remove the cervix firat ; then,
by dilating the upper canal sufficiently to admit the diverg-

knife

FiQ. 53. — Second step in high amputation of ct

tenac

Making the deeper incisions.

ing volsellum, once more proceed as in the first instance,
taking care, however, to keep within bounds (Fig. 54),

It will be found that the cupped stump can now be
drawn down and made to project as a more or less convex
body.

In all cases the dome-shaped electrode (Fig. 55) should
be passed over the entire cavity re|>eatedly so as to render
the cauterization still more complete.

TREATMENT OF CANCER OF TilE LTEIiUS. 75

It is important to add tbat, in caiTyiiig tlie knife towai-d
the «i(/f» of the cervix, circular and other arteiial branches

Pio. 54. — Cerrix having been

are likely to be encountered, and hence, in this locality par-
ticularly, a high degree of heat in the platinum blade is to
be carefully avoided. As an additional security against
hasmorrhage, the convexity of the » g ag.

knife should be pressed against ' • ^^

the external surface of each par- ^"'- 55-i>''™^-=i"'t*<i .\,ctr.,^,.

I ticular section cut, so as to close the vessels more effectually.

I (Figs. 56 and 57.)

It is well to state that the metallic parts of the elec-

[ trode for the dlstitiu'e of uhixif tiro inches should he covered

' with a str//i of thiih fa>uii-l. ■•m thiit the vagina may be pro-

\ tected from, injury through the n-ftdeil heat.

VAGINAL IIYSlURECTmlY IN CARCINOMA CTERI

Vaginal hysterectomy offers superior opportunities for
I the use of the hiemostatic furceps in arresting hsemorrhage.
VI have tried every known method of doing this opemtion,

7H ELECTRO- il.KMOSTASIS IN OPERATIVK SLTROERY.

and fcmiid tliem all objectionable, ami so I waa led tn do
the (>|>eratit.>n as follows; The geueral preparation of the
patient is the same as for all major operations, but the
cleansing and disinfecting of the vagina is difficult and
requires special care.

If the body of the uterus alone is affected, the cervical
canal must be washed out, paeked loosely with cotton, and
closed with a paii" of forcejw or with sutures. If the dis-

ease involveH the cervix, so that the cancerous mass pro-
trudes into the vagina, it should be removed with the cau-
tery or curette, and then the canal closed in the manner
described. The object of this closure of the canal is to
keep the parts clean and fi-ee from infection during the
removal of the uterus.

It is always difficult to make the vagina and external
genetalia aseptic, but in cancer of the uterus it is well-
nigh impossible. On that account, I have removed the
cancerous gi-owths from the cervix preliminary to hysterec-
tomy, and then made the parts as clean as jiosaible.

TREATMENT OP CANCER OB" THE UTERUS. T7

This can be done without anaesthesia if the patient has
ordinary self-control and the operator is dexterous. To dis-
infect the vagina and external genitals, I use when at hand
an antiseptic solution of bichloride of mei-cury or carbolic
acid and glycerin applied under high pressure from an
atomizer. In that way the solution is foi'ced into aU folds
of the tissues most effectively.

Pia. 57. — Charred cup-shaped stomp after removal of cervix, (Byrne.)

Retractors aliould be introduced into the vagina, so as
to expose the cervix and upper part of the vagina The
cervix should then be seized with a volsellum forceps and
drawn outward and upward, and the posteiior vaginal wall
incised, the incision being semicircular and extending half
around the cervix and outward half an inch or less, aecoi'd-
ing to the size of the cervix. The
peritoneum should be opened from the
base of one broad ligament to the
other. The anterior vaginal wall is
then circumcised, and the uterus and
bladder separated up to the perito- fig. 58.— Oiii__ __.
neum with the dry dissector or the l^nhiarwai!"
finger. I prefer not to open into
the peritoneal cavity in front until the broad ligaments are
separated from the uterus up to and including the uterine
arteries. The vagina is sej^arated from the uterus with the

78 ELECT HO-ILllMOSTASIS IN OPERATIVE SURGEltY.

kuife, scissors, or galvano-cautery knife. I prefer tlie cau-
tery. (See Fig. 59.)

The lower portion of the broad ligament is then seized
with the hiBmostatiii forceps aa close to the uteros as

seized I

poaai- j

80 BLECTRO-HiEMOSTASTS IK OPERATIVE SURGERY.

ble, and tlie lieat turned on. The compression is increased
while the heat is being applied. While the forceps is

^F[(J. 63.— Shield forceps tor u
being applied to the broad ligament the bladder and ante-
rior vaginal wall are held away from the forceps with a
retractor to protect them from the heat. The tissues are
protected frem the heat posteriorly by means of the shield
forceps shown in Fig. 62, whose shields cover the backs of
the heated jaws, and are set at an obtuse angle to their

blades so that they do not interfere with the manipulation
of the electrical instrument.

The shields are constructed of hard rubber, with a thin

TREATMENT OF CANCER OF THE UTERUS. 81

metal core to give strength, and, being poor conductor of
heat, effectually protect the adjacent tissues from injury.

A little practice is needed in order to know the length
of time that the heat should be continued. When one is

doubtful about this, the forceps may be removed and tlie
parts inspected; and, if need be, the forceps i*hi>uld be re-
applied and the lieat continued long enough to obtain the
desired effect. The ligament is divided with knife or

82 ELECTRO-n^MOSTASlS IN OPERATIVE SURGERY.

scissors between the forceps and tlie uterus as far up as
the vessels have beeu closed. Tlie lower portion of the
ligament on the other side is treated in the same way.
The uterus is drawn down, and the remaining portions of
the ligaments are treated in sections until the uterus is
completely freed. (See Figs. 63 and 64.) The operation
may be briefly described by saying that it is performed in
the same way as when forceps are used to control the
bleetling (commonly called the French method), with the
difference that instead of leaving the forceps on long enough
for the compression alone to arrest the haemorrhage (twenty-
four or forty-eight hours), the heat completes the hsemo-
stasis, and the forceps is remove<l at once.

After the uterus is removed a careful examination of
the parts should be made, and if any portion of the broad

■Diagram showing sutures ready to be tied.

ligaments shows that the disease ha.-^ extended beyond the
uterns, the suspected parts shouM be remt)ved. Tliis is done
by seizing the stump with a fixation forceps and making
traction enough to bring the part within reach and then
applying the haemostatic forceps outside of the traction
forceps and desiccating sufficiently to destroy the diseased

TREATMENT OP CANL'EIt OF TIIK UTERUS. 83

tissue. The cavernous tissue ia completely destroyed by the
electric heat ajiplied in this way, and the results ai'e aa
good as if the pait had been exsected. According to Dr.
Byrne, cancer can be eradicated in this way at points in
deep pelvic structures that can not be safely I'eached by the
ordinary methods of extiipation.

The next step is to sponge the field of operation dry and
clean, and then unite the peiitoneum to the auteiior and

Fni. 66. — Diagram showing sutures tied.

posterior vaginal ^valls with fine catgut sutures. The
jwritoneal cuts should be sponged clean. One end of each
suture is then cut off and the remaining ends are tied to the
opposite sutures, thus completely closing the \vound, except
in the center, ^vhere space enough is left to admit a small
gauze drain, (See Figs, 65 and 66.) The vagina Is loosely
packed with gauze, and the operation is completed.

The ad\'antages which may be fairly claimed for this
method of doing hystei'ectomy are many in favor of both
patient and operator. In the fiint place, and most desir-
able, it is a bloodless operation. Most of the patients hav-
ing cancer are anaemic and can ill afford to lose blood.
Then the operation can be done in less time than in any

84 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

other way, excepting by the so-called French method,
which is most unsatisfactory in its results, and should not
be considered in comparing the operations. Again, there
is no pain and little if any constitutional disturbance. Be-
sides, the time required for recovery is the shortest on
record, and, judging by my own experience, the mortality
is less than one haK of one per cent. In addition to all
this, the broad ligament stumps are reduced to the smallest
size, the blood-vessels and lymphatics are completely closed,
and hence the process of repair, which takes place by reor-
ganization, is accomplished in very little time, and the
thorough disinfection of the stumps by desiccation guards'
against reinfection and immediate recuirence of the disease.
The time and taxation saved on the pai*t of the surgeon can
be realized only by one who has repeatedly operated in
both this and other ways.

ELECTROCAUTERY IN THE TREATMENT OP PELVIC AB-
SCESS AND DISEASES OF THE VULVA AND VAGINA

Pelvic inflammations ending in abscess were all treatetl
by opening from the vagina in the times when salpingitis
and ovaritis were not understood. At that date there were
many cases requiring such treatment. But after the re-
moval of diseased Fallopian tubes by abdominal section be-
came established surgery, the vaginal route of getting at
pus in the pelvis was given up. Within the past few
years, and since vaginal hysterectomy has been perfected,
vaginal section has become as jwpular as abdominal section
was. I never gave up vaginal section for pelvic abscess in
a given class of cases. I refer especially to pelvic cellulitis
following parturition and secondary pelvic cellulitis caused
by pyosalpinx with extensive adhesions, and in cases of
general pelvic inflammation in which the pelvis is filled
with the products of inflammation, so that the organs first
involved, be they ovaries or tubes, and the site or depot of
suppuration can not be removed by ccellotomy.

There ai'e really three forms or conditions which call for
vaginal section : the one a pyosalpinx, lying in the most de-
pendent part of the sac of Douglas and bound down by
pro<lucts of infiammation which fill the upper part of the
pelvis ; the other \vhere by ulcerative perf()ration the tube
has opened into the cellular tissue of the broad ligament
and there developed a cellulitis ; and, finally, primary cellu-
litis following parturition or septic injuries of the cervix

uteri.

86 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

Treatment. — The preparation for the operation and the
position of the patient should be the same as in vaginal
hysterectomy. The posterior fornix of the vagina being
exposed by retractors, the vaginal wall should be divided
with the cautery knife, heated while in contact with the
tissues, throughout the entire width of the cervix uteri
and outward on either side, in case the cervix is small, for
half an inch. It sometimes happens that a divided vessel
bleeds freely. That should be controlled by seizing the
tissue at the bleeding point with a haemostatic forceps and
heating until the haemorrhage is controlled. At this stage
of the procedure an examination should be made for fluctu-
ation or a soft part in the mass behind the uterus. If no
such spot is found, a curved aspirating needle should be
introduced to search for pus; when found, the needle
should be left in place as a guide for the incision with the
cautery. When the incision is made large enough to intro-
duce the finger, a further examination should be made to
determine whether there is one abscess or many. If the
latter, the walls between them should be broken down and
the cavity thoroughly washed out with carbolized water or
such disinfectant as the surgeon prefers.

The wound should be enlarged in case it is not sufficient
to secure free drainage. I prefer a roll of gauze, large
enough to fill the wound ,and long enough to extend up to
the upper portion of the abscess cavity. This drain of
gauze should be removed at the end of twenty-four hours,
and the cavity again irrigated and the smaller gauze drain
used. This change of drains is most easily made with the
patient in Sim's position. After this a double rubber
drainage tube should be used and held in place by a suture,
carried through the edge of the wound and the tubes. The
cavity should be washed out daily until the sac contracts
down, then the rubber tubes should be removed and a
small pledget of gauze placed into the vaginal wound until
the cavity is completely closed.

ELECTRO-CAUTERY IN TREATMENT OF PELVIC ABSCEHS. 87
CYSTS OF TUE LABIA

Complete exsection ia the proper treatment of the cysts
that are quite frequently found in the labia. But this has
proved to be very difficult in my practice, and I infer from
reports that others have uot been much more successful. I
have tried in a great many cases to I'emove such cysts with-
out rapture, but have invariably failed. The cyst wall is
very thin, and so closely adherent to the surrounding tissue,
e8j>ecially at the deepest part, that complete enucleation is
impossible, so far as my experience goes. Lack of success
drove me to seek some more satisfactory metliod of operat-
ing, which I found in the following: In the large cysts
that were near the surface, by making a free incision with-
out wounding the cyst wall, I have succeeded in separating
the cyst from the gi-eater portion of its attachment ; and
by retracting the sides of the wound so that the base of
the attachment was brought within easy reach, and then
applying a narrow-bladed haemostatic forceps to control
bleeding and compi'ess the tissue and form a stump, the
stump is divided at the desiccated point, and the cyst set
free thereby.

In some cases it is necessary to separate the adhesions
in sections ; that is to say, a [lortion of the cellulai' tissue is
seized by the forceps, compressed and desiccated, and then
divided in the center of the desiccation ; another portion is
treated in the same way until the cyst is completely liber-
ated. All bleeding being airested by the process, the
wound can be closed with sutures, and healing proceeds
without interruption as a rule. The cyst will be ruptured
sometimes, though the greatest care be taken ; then the
next best thing to do is complete cauterization of the cyst
wall. The wound is held open with forceps or tenacula
and a fine cautery point or knife blade passed over the
surface until every j^)ortion of the cyst wall is cauterized.
The cauterization should be very superficial, but complete.
If any jxirtiou of the cyst wall is left undestroyed, it will

88 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

continue to secrete and retiinl healing, or form another
cyst.

When cauterization is employed, the wound should be
left open until the charred tissue separates and is thrown
oil. When this separation takes place it is necessary to
wash the debris away or sponge it out of the wound. The
healing process goes on very rapidly under the crust of
charred tissue, and when this separates, the closure of the
cavity or wound is completed in a very short time.

This method of operating upon labial cysts involves
much more time and trouble than the old way, but the
comparatively little after-care retjuired, the shorter time of
recoveiy, and the relief from suilering, more than compen-
sate both the patient and the surgeon.

CYSTS OF THE VAGINA

These cysts of the vagina are caused in some cases by a
closing and distention of the vaginal glands, but they more
frecjuently are developed fn)m distention of Gartner's ducts,
a portion of one of them remaining patent.

This has been clejirly [>ointed out by Amand Eouth in
his moat interesting article in volume xxxv of the Transac-
tions of the Obstetrical Society of London. Their recog-
nition is not difficult, provided that a careful inspection is
made of the vaginal canal. The treatment Avith the gal-
vimo-cautery is easy, and the results good. A free incision
is made with the cautery knife through the vaginal wall,
the cyst is laid open, and the cyst wall cauterized with the
knife blade applied flatAvdse. The healing is accomplished
in K^ss time than when the incision is made with the
knife ; the bleeding vessels are ligated, and caustic is used
to destroy the cyst wall.

Were it possible to remove the entire cyst intact by dis-
section, and to close the wound with sutures, that would be
the most })erfect procedure.

ELECTKO-CAUTKRY IN TKKATMRNT OF PELVIC ABSCESS. 80
VARIC08B VEINS OF THE VULVA

The veins about the vulva, like thoBe in other portions
of the body, may take on a, vancose condition. This com-
monly occurs in those who have borne children; and, in-
deed, pregnancy appeal's to etaiid in a causative relation
thereto, although cases undoubtedly do occur in those who
have never been pregnant.

Causation. — Anything which obstructs the venous cir-
culation will, by increasing the intravenous pressure,
tend to produce this varicose condition, whether it be
a pregnant uterus, a tumor, or, aa mentioned by Winckel,
the straining at stool, in case of obstinate constipa-
tion.

Symptomatology. — A patient may have well-marked vari-
cose veins of the vulva, and yet be entirely unaware of the
fact. Or a sense of heat and initation may be experienced
of so disagreeable a nature as to cause her to consult a phy-
sician, when the presence of vai'ia)se veins may be recog-
nized. In still other cases the enlargement or swelling is
so great as to attract her attention, though other symptoms
may be iilisent.

I'hyxiral Signs. — Upon examination, in slight cases, the
vai-icose condition of the veins is oljserved, and the swelling
disappears on pressure, but returns immediately when the
pressure is removed. However, in more aggravated cases,
there may be so nuich tumefaction of the labia and other
parts as to mask this peculiar condition of the veins. IIol-
den de8crii)e8 a case in which a tumor existed as large as
the heafl of a child.

The diagnosis in these cases is to be made by excluding
other affections, such as hernia, hiematocele, cysts, and cellu-
litis.

Sui^cal treatment should be limited to cases that are
sufEering, and in which there is danger of rupture from the
extreme distention of the veins. Indeed, the only operative
treatment adviseil is ligation and exseotion of the veins.

90 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

This has not been very satisfactory, owing to very slow
recovery.

The method of operating which I have adopted is as
follows :

An incision is made through the skin over the most
prominent part of the mass of veins. The skin and sub-
cutaneous tissues are separated from the vessels with the
scissors or dry dissector, until the parts to be removed can
be drawn out of the wound. Then when possible the cen-
tral portion of the mass is dissected out, leaving the veins
attached above and below ; the upper end of the veins is
grasped with the forceps, compressed and heated until they
are closed firmly. The lower end of the veins should be
treated in the same manner, and the whole mass cut away.
Any small vessels in the wound that bleed should be closed
with the haemostatic forceps, and the wound closed with
sutures. While the haemostatic forceps is being used, the
shield forceps should be placed underneath to protect the
tissues from the heat in the way described in treating the
pedicle of an ovarian tumor.

K the mass of distended veins is not very large, they
can all be seized in one grasp of the forceps, and treated in
one piece and not in two sections.

This method of operating is so easily carried out, and
recovery is so uneventful, that I have employed it in cases
of lesser degree of development. I have the impression
that the method might be employed in treating varicose
veins of the legs.

Contused Wounds of the Pudendum. — These are of
two degrees of severity. A slight bruise, causing rupture
of only a few small vessels (which very soon stop bleeding),
gives rise to an ecchymosis, which quickly disappears. Oc-
casionally inflammation follows, and an abscess develops,
which is managed in the usual way. More severe are con-
tused wounds which rupture the large vessels of the bulbi
vestibulares or existing varicose veins of the labia, and pro-
duce pudendal haematocele— -^. ^., an accumulation of blood

ELECTRO^CAUTERY IN TREATMENT OF PELVIC ABMCESS. 91

in the loose cellular tissue of the parts. The pathology of
this injury is the same as that of bruiseB or contused wounds
generally. There are laceration of the vessels and hsnioi--
rhage into the cellular tissue.

In contusion of the pudendum two conditions coneijiie
to make the iujuiy grave in character — the large size of
the vessels wounded, and the loose character of the cellular
tissue, which admits of a very large accumulation of blood.
The size of the hsematoma depends upon the size of the
vessels lacerated. In case the vessel is small, the bleeding
may be controlled by the pressure from the blood in the tis-
sues; but when large varicose vessels oi' the vessels of the
bulb of the vestibule are lacerated, the size of the hsemato-
eele is very great. I have seen one neai'ly as lai^e as the
two fists.

The course and termination of the hsematocele vaiy. If
the blood-clot is small it may disappear by absorption with-
out causing much discomfort, after the first pain of the
injury subsides ; but when the accumulation of blood is
large, then inflammation follows which may tenninate in
sloughing or suppuration, and finally septicaemia.

Symptomatology. — The symptoms are pain following
the injury, and then a feeling of fullness, heat, and some-
times throbbing. In one case that came under my observa-
tion the pressure was sufficient to prevent unuation, and it
was very difficult to pass the catheter. The attention of
the patient being directed by the j>ain to the location of
the injury, she discovers the swelling by the touch.

Phydval S/ffiifi.—The jihysical signs vaiy in the differ-
ent stages of the disease. At first the tumor is elastic aud
like a local oedema, except that it does not pit on i)res8Ure.
After the blood has coagulated the parte are denser and
slightly irregular or slightly nodular ; discoloration of the
skin occni-s in twenty-four hours, or less. (Edema of the
skin also occurs.

Dmgnoms. — In regard to the diagnosis, it may be said
that pudendal haematocele can hardly be confounded with.

92 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

any of the diseases of the pudendum except pudendal hernia ;
but the mode of development and })hysieal signs of the two
affections are so unlike that the differentiation is easy.

Causation. — The causes of pudendal hsematocele are
predisposing and exciting. Varicose conditions of the ves-
sels, degeneration of the vessel walls, and marked engorge-
ment from any cause which interrupts the venous circula-
tion, render the vessels more susceptible to rupture when
subjected to any injury.

Pregnancy predisposes to rupture of the pudendal ves-
sels, and labor is one of the most prominent of the exciting
causes, but the present discussion of this affection is limited
to causes occurring in the nonpuerperal state. The reader
will find a very full account of this affection, as it occurs in
labor, in a monograph by Prof. Fordyce Barker.

In regard to the exciting causes of the affection, it may
be said, in brief, they are always traumatic. Difficult labor,
direct blows, are the usual means by which the vessels are
ruptured ; indirect injuries — from a fall, for instance — ^might
produce rupture of the pudendal vessels, but I have not
seen any case in which the injury was caused in that way.

TreaPment. — When the patient is seen while the bleed-
ing is still going on, a free incision should be made through
the skin and the blood pressed out, the bleeding vessels
seized singly or in mass with the haemostatic forceps and
closed by the pressure and heat. The wound is then closed
with sutures.

In cases of longer standing in which a hsematoma has
been formed by the coagulation of the blood, the incision
should be made with the cautery knife and the blood-clot
turned out. Since the cellular tissue is infiltrated with
blood, the whole coagulum can not be removed without
starting bleeding. Hence it is necessary to control the
bleeding vessels in the way described. The cavity being
thus freed from blood-clots and the bleeding completely
controlled, it should be packed with gauze and allowed to
heal fi'om below outward.

ELECTRO-CAUTERY IN TUKATMENT OP t'ELVIC AUSCKl

I liave operated by making the incision with the knife
and ligating the vessels, and am able t<i conipai't' the old
method with the new. The mivantages are all witli the
new method of operating.

CAllBUNCLE

All surgeons agree that free incision is indicated in car-
buncle, but they admit that there are oljjections to the uwe
of the knife, chief among them being the Ions of blood that
can ill be spared by the subjects of carbuncle, for they are
always in a low state of general healtli.

There is, in my oj)inion, still another ol>jecti<>ii of equal
importance, and that is the ab8oii)tion of septic matter from
the incised wound, which causes a further, and often dan-
gerous deterioiation of the general health.

These objections are met and the dangers avoide<l by
using the cautery knife in making the incisiou. It is desira-
ble to open a carbuncle before death of the deejH'r tiftsues
takes place. At this stage of the disease one free iiiciHlon
through the skin, extending across the parts involved, is
requiretl. When the skin is divided the tension is usually
sufficient to throw the wound ojien so that the incision can
be continued down thnmgh all the tissues involved. When
the carbuncle is large and induration well marked, two sub-
cutaneous incisions should be made at light angles to the
first. Clean gauze should be placed into the wound t*)
keep it open and permit the serum, which soon begins to
ooze from the tissues, to escajie. There is no Iweniorrhage
if the incisions are made slowly and with a knife at ro<l
heat and the wound surfaces are rendered incapable of
absorption. The pressure is taken off the I >lo(«l- vessels,
the circulation is re-established, and necrosit* prevented.
When necrosis has taken place the whole of the dead tissue
should be e.xsected. That can \te d<jne by making a circular
incision, retracting the edges of the incision in the skin, and
with the cautery knife dissecting out all the necrose<l tisxue.
It is necessary to keep within the line of deniarcotiou Ik^

94 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

tween dead and living tissue. The separation of the core
or necrosed tissue can be quickly done because the tissues
are softened and bloodless. If by chance any portion of
the dead tissue is left it can be easily seized and cut off.
It sometimes happens that a large artery spurts, having
been too quickly severed with the cautery knife. In that
case it should be seized with the haemostatic forceps and
closed. A gauze packing should be loosely applied and
left until it becomes saturated with the discharge.

Before the thin crust of charred tissue separates, the
healing process is well advanced, so that an ordinary gauze
dressing is all that is required to complete the treatment.

CHAPTER X

ELECTRn-ir.EMOriTASIB IN EXTIRPATION OF THE MAMMARY
AND LYMPHATIC GLANDS

I CONTINUED to use the ligature for controlling the haemor-
rhage in extirpation of the mammaiy gland long after I had
given it up in all my other surgical work. This was owing
to the fact that the classical method had given general satis-
faction. Occasionally there would be suppuration and de-
layed healing, but such imperfections \vere attributed to
some surgical sin of commission or omission on the part of
the operator and assistants. Then a rigid iti\-estigation
would be made in order to discover the source of infection.
Some possible cause of the objectionable effects were usually
discovered, but in no case was the ligature found guilty or
responsible, excepting on one occasion when there was cause
for a suspicion that the catgut used was not aseptic. There
was no reason in this to induce me to ^ve up the ligature, so
I continued to use it in this operation, until my first assistant
said that he had forgotten how to tie a ligature, and, what
was more to the point, the fact of having forgotten to pro-
vide clean, reliable catgut ligatures, suggested that the
hemostatic forceps should be used in the extiriiation ojiera-
tion then on hand. Though believing that more time would
be required to operate in this way, there was no a]>parent
objection to trying. The operation was perforaied accoixl-
ingly and proved to be so gratifying that I have followed
this method ever since. Not that this method of operating
has proved to be so much superior to the old way. but
because it has been more satisfactory in being followed

96 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

by less pain and a shorter period of recovery, and saves all
the trouble and time of obtaining reliable catgut ligatures.

There are so many ways of preparing catgut ligatures
that one is in doubt regarding which to choose, and I find
that many surgeons prefer preparing their own, or to have
them prepared by assistants, rather than to obtain them
from dealers in surgical supplies. This involves an amount
of labor and trouble, and withal a feeling of doubt which
the surgeon would gladly escape, I am sure. Perhaps this
doubt regarding the sterility of catgut ligatures is personal,
and others may have confidence in them when prepared as
they direct or practice. I can only say that, not having
time to prepare my own ligatures myself, I always have a
fear that they may be imperfectly treated or contaminated
in keeping. Therefore this made me the more willing to
give up ligatures in removing the mammary gland, though,
as already stated, I was fearful that more time would be
required to control the bleeding with the new haemostatic.
My opinion on that subject was a mistaken one. In actual
practice I saved time.

Operation. — The incision is made and the gland and sur-
rounding adipose tissue exsected in the usual way. As the
arteries are divided the assistant catches them with ordi-
nary compression forceps to temporarily control the bleed-
ing. When the whole breast is removed and all suspicious-
looking parts of the fascia and muscle, each forceps is
removed in the order of its application and the haemostatic
forceps applied exactly to the part from which the other
forceps has been removed ; the heat is turned on for a half
or a quarter of a minute ; the assistant holds the forceps
while the heat is being applied, and meanwhile the operator
applies the haemostatic forceps to another artery and trans-
fers the current from one forceps to another. The forceps
is left on for a time after the current is discontinued. This
is done because I found that the heat in the forceps was
suflGicient to continue the desiccating for some time after
the heat supply was cut oif. It will be seen from this

EXTIRPATION OP THE MAMMARY AND LYMPHATIC GLANDS. y7

account that two or three arteries cau be under treatmeut
simultaneously and much time saved there})y.

In looking over the history of cases I find one of extir-
pation of the mammary and axillary glands performed in
half an hour, and another in forty minutes. This comiMires
very favorably with operations in the old way so far aw
time is concerned.

In extirpation of the axillary glands for cancer con-
nected with disease of the breast, I have found this method
of controlling hsemorrhage very satisfactory.

The uiainniary gland is first removed, then the incision
is continued along the border of the i^ctoralis muscle ; the
glands and adipf>se tissue are then dissected away from the
skin and fascia. Each gland is isolated with the diy dis-
sector and fingers, and drawn away from the large vessels
and nerves ; in other words, they are made pedunculated.
A narrow-bladed lispmostatic forceps is applied between the
gland and the vessels and nerves, the heat used long enough
to close the vessels, and then the glan<l is cut away. By
being careful in separating the glands from the vessels in
this way there is less danger of injuring the vessels, the
lai^e veins especially.

The results that follow compare favorably with those
obtained by other surgeons, and are superior in several re-
8i>ects to those obtained in my own practice by ojierating in
the usual way. There is less jmiu and the healing pi-ocess
is completed in much less time. This can be best illustrated
by the following notes of a case recently treated : The
patient was operated upon years ago at different times for
laceration of the cervix uteri, laceration of the [lelvic floor,
and rectal hfemorrhoids ; subsequently one of her ovaries
was removed by vaginal section ; last of all her right l>rea8t
was extirpated for cancer. Her exjierience certainly quali-
fied her to judge nf pain after surgical treatment. Her
testimony regarding the last operation was that she ha<l no
pain whatsoever. Tliere was no rise in temj)erature, and
the pulse after her recovery from the auasthetic remained

98 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

normal throughout her convalescence. Her appetite and
nutrition were normal, and she slept well. On the morning
of the fourth day she left her bed and was about her room.
The sutures were removed on the seventh day, all of them
coming away dry and without any bleeding. Two drops of
clear serum escaped from the track of one suture after its
removal ; union was complete and perfect, and there was no
swelling or induration of the parts. There was no traction
upon the edges of the wound. A thin layer of sterilized
cotton was placed over the chest and a bandage applied.
This dressing was removed on the twelfth day and was
found to be dry and clean. At that time the process of
repair was complete. There was no tenderness anywhere,
the skin was everywhere movable upon the thorax to a
slight extent, and the arm could be moved in every way
without pain. Such perfect healing of the skin incision
and between the skin and deeper tissues of the thoracic
wall I have never known to take place in so short a time when
a number of ligatures were used to control the bleeding.

A comparative study of this and others operated on in
this way indicates that the process of repair is simpler and
is completed in less time than in cases in which ligatures
have been used, and have to be disposed of by absorption
or becoming encysted. Therein the clinical phenomena and
the laboratory experiments coincide, and prove as clearly
as need be that the use of the haemostatic forceps has just
claims upon the surgeon's confidence in regard to the repair
of wounds.

Having found that extirpation of the breast is a rather
long operation, owing to the time required to arrest the
haemorrhage, I was of the opinion that the new haemostatic
would prolong the operation still more ; but, as already
hinted at, less time was required to close the arteries com-
pletely and leave the wound so dry that no drainage was
required. More time was needed to close the large vessels
than if the ligature had been used, but the small vessels,
ignored by some operators, which I always take pains to

EXTIRPATION OF THE MAMMARY AND LYMPHATIC GLAKDS.

stop, were managed in less time, ao that a complete drjing
state of tlie wound was obtained in as little or even lesa
time than I had ever employed while operating in the old
way. This may be made clear by giving an illustrative
case : The patient had carcinoma involving about two
thirds of the left mammary gland. The tumor was not
large ; the skin was not perceptibly involved, but the axil-
lary glands were very large, indurated, and matted together,
forming one irregular mass a third of the size of the turaoi'
in the breast. I do not remember having seen the axillary
glands so extensively involved in connection with so moder-
ate an advancement of the disease in the breast.

By an unexplained omission the blood had not been
examined, and I was surprised by the discovery, during the
operation, that she was hiemorrhagic. There was no great
vascularity apparent, and I was not expecting any trouble
with the hsemon-hage, nor were the principal ai-teries large,
but the smallest vessels kept on bleeding so that I was
obliged to close them after the removal of the breast and
before clearing out the axillary glands. Troublesome
hfflmorrhage was anticipated in removing the lymphatics in
the axilla, but I was pleased to find that I had less ti-ouble
than was exjiected. Some bleeding was avoided by not
extending the incision of the skin as far ui)ward as usual,
and there being no adhesions of the parts to the muscles,
there was no bleeding from small muscular ai'teries such as
were so troublesome in the breast part of the operation.
The main arteries were treated in the way described in the
first operation given, and the small ones were caught in the
small artery forcejis (which was kept heated continuously)
and held for the few seconds required to stop them. The
small arteries in exposed muscles aud in the skin were the
most difficult to manage; still they were all closed and
the wound made quite diy, far more so than I could have
made it by using ligatures. The surface of the wound was
freely studded with the stumjis of closetl vessels, but was
smooth and clean compared with \vhat it would have been

100 ELECTRO-H^MOSTASTS IN OPERATIVE SURGERY.

if I had used ligatures. How long it would have taken me
to operate if I had used ligatures I do not know, but I am
very sure that I could not have so completely arrested the
haemorrhage in a bleeder like that one by ligation, and I
have never been able to do such an operation in less than
forty-five minutes, the time required in this case.

The incision in the skin was made short to avoid
haemorrhage and to save the necessity of many sutures, the
latter giving great advantage, because needle punctures
bleed freely in such patients. Only two sutures were em-
ployed, and the remaining part of the wound closed with
adhesive strips. The healing was without interruption.
There was no suppuration and only a very little escape of
pinkish-colored serum during the first day after the oper-
ation.

EXTIRPATION OF DISEASED LYMPHATIC GLAISDS

The affections of the lymphatic glands characterized by
enlargement that call for extirpation are not to be con-
sidered here. The classical method of exsection gives entire
satisfaction no doubt, but in scrofulous and tubercular dis-
ease of the glands in the inflammatory stage, especially
when there is suppuration, much more gratifying results
can be obtained by operating with the galvano-cautery.
At least, such has been my experience.

The method of operating should be adapted to the con-
dition present in an adenitis in the first stage — that is, be-
fore suppuration has taken place. The incision is made
with the cautery knife through the skin, and the adhesions
of the gland to the neighboring parts separated by dry dis-
section ; vessels that are large enough to bleed are closed
with an application of a haemostatic and divided. Very
often the main artery which supplies the gland is imbedded
in a mass of exudate and cellular tissue from which it can
not be isolated. In that case the whole mass should be
treated with the haemostatic forceps and the gland set free
by dividing the desiccated portion of tissue containing the

EXTIRPATION OF THE MAMMARY AND LYMPHATIC GLANDS. 101

vessels and nerves. Small bleeding vessels that are found
should be closed, and any exudate or products of inflamma-
tion that have been left should be dissected out and the
cavity loosely packed with gauze and an aseptic dressing
applied.

At the end of twenty-four hours the gauze packing
should be removed and the wound redressed. It is not
necessary to introduce any drain afterward at the second
dressing, unless the wound is very deep ; the incision in the
skin having been made with the cautery, the surface wound
will not heal before the cavity is closed.

Suppurating cases are operated by first opening into the
abscess with the cautery knife and removing the gland tis-
sue and inflammatory products with a curette, thoroughly
washing out the cavity and drying it, and then superficially
but completely cauterizing the surface ; finally packing and
dressing, as described above.

This method of operating in suppurating tubercular
disease of the glands gives superior results, as indicated by
a speedy and complete recovery. Making the incision with
the cautery knife prevents haemorrhage and reinfection, and
the cauterization of the cavity surface arrests the suppura-
tive disease so that recovery promptly takes place, instead
of continued suppuration and extension of tubercular infec-
tion, which so frequently follows after evacuation by curet-
ting alone, and finally the scar is smaller than that which
follows the usual way of operating.

CHAPTEK XI

ELECTRO-HiEMOSTASIS IN EXTIRPATION OF TUMORS OF THE

BLADDER

In times past I had considerable experience in the treat-
ment of neoplasms of the bladder, according to the methods
given by the best surgical authorities.

Either vaginal or suprapubic cystotomy was performed,
the choice between the two avenues of approach being de-
termined by the location of the growth to be removed.
When the part to be removed was reached, it was cut off
with the scissors or removed with the curette, and the
haBmorrhage stopped by ligation of the vessels or the appli-
cation of such styptics as hot water, persulphate of iron, or
acetic acid. The bladder was drained until healing took
place. I never cured a case in this way, and I am not sure
that the life of the patients was prolonged by the treat-
ment. In fact, in two of my patients life was probably
shortened, though great relief was given by the treatment.

With such discouraging results before me I determined
to try the clamp and cautery method of operating.

The first removal of a neoplasm, supposed to be malig-
nant, from the bladder with the clamp and cautery was
one in which I was able to make an accurate diagnosis of a
tumor, about an inch and a half in diameter, on the upper
part of the anterior wall of the bladder. The patient had
for months suffered almost continuously from hsematuria.
I made a vesico-vaginal fistula by dividing the tissues with
the knife and scissors ; then, by having pressure made above
the pubes and raising the vaginal wall, brought the tumor

102

EXTIRPATION OP TUMORS OF THE HLADUER. 103

down to the vaginal fistula, and succeeded in drawing it
thTOUgh into the vagina, and with it, of course, a portion of
the antenor wall of the bladder. I clamped the base of
this growth with the forceps and then cut it oS with the
cautery, and, applying the cautery to the blades of the for-
cep, desiccated the portion within the grasp of the forceps,
most of which was normal mucous membrane ; the forceps
was then removed, the bladder thoroughly washed out, and
the vesico-vaginal fistula closed with silk sutures. The
bladder was drained with a retained catheter for twenty-
four hours after the operation, and then catheterized every
four hours for three or four days. The patient made a
complete reeoveiy. Having succeeded so well with the
clamp and cautery, I was led quite naturally to expect that
still better work could be done with the haemostatic for-
ceps ; and soon after that instrument was devised, I found
an opportunity to try it, and it came (juite up to my highest
expectations.

This, in brief, is the story of the evolution of the present-
time operation for neoplasms of the bladder.

EXTIKPATION OF NEOPLASMS OF THE BLADDER THROUGH A
VESIOO-VAGINAL FISTUT^

Single tumora of small size attached to the bladder wall
at any point, excepting the middle of the jxisterior wall,
can be removed through a vesico-vaginal fistula, and it is the
best way of operating.

The patient is placed in the Sims position, and an open-
ing made in the median line large enough to permit the
tumor to pass through. The vaginal wall is pressed ujv
ward with a long forceps, the open blades of which are
placed against the edges of the fistulous opening. An as-
sistant makes pressure over the hypogastric space to crowd
the bladder down to the opening, and force the tumor out
into the vagina. The operator holds the forceps which sup-
ports the vaginal wall in his left hand, and aids in the de-
livery of the tumor with a small sponge in a holder. The

104 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

sponge is used instead of the traction forceps to aid in the
delivery of the tumor, as the tissues are always friable, and
the forceps would tear them. When the base of the tumor
is thus brought into view, the haemostatic forceps is applied,
and a thin shield adjusted to prevent the heat from injuring
the bladder or mucous membrane, and also keep the partial-
ly inverted bladder from getting away from the operator.
It is better to include a portion of the mucous membrane
of the bladder in the haemostatic forceps than to run the
risk of letting any part of the diseased tissues escape. The
heat should not be above 175°, but should be continued for
two minutes and a half ; and very little traction should be
made on the forceps, because the tissues are friable and
easily torn from their attachment to the bladder walL
When such a mishap occurs, the bleeding should be con-
trolled by singeing the points that bleed with a small haemo-
static and closing them, or a cautery below red heat may
be used.

The tumor is cut off close and the forceps opened
enough to loosen their hold, and the stump is permitted to
escape by slipping off the forceps as one would take a ring
off the finger. In that way the delicate stump is not torn.
Formerly I washed out the bladder before closing it, but
that is not necessary.

The opening in the bladder is closed with silk sutures,
and drained for a day or two with a catheter of soft rub-
ber. Fig. 67 shows the tumor crowded out through the
opening, with the forceps and shield in place.

The Suprapubic Operation. — Large and multiple neo-
plasms and those inhabiting the lateral walls and base of
the bladder can be successfully removed only through the
suprapubic opening.

In addition to the usual preparation for the operation
the bladder should be thoroughly washed out and disin-
fected, using every care not to start bleeding. A mild
solution of acetic acid is the best, as it is a good styptic
and a fair disinfectant. The bladder should be filled but

EXTIRPATION OF TUMORS OF THE BLADDER. lOil

not be distended with air or water, and kept so until the
opening is nia<le. Distention invaiiably causes haemorrhage
less or more, and complicates the operation.

The opening should be made as large as possible ; the
edges of the wound held apart with retractors, and the
interior illuminated with dii'ect oi' lefracted light. The
bladder is emptied with the catheter and then sponged
diy. In case there are a numbei' of growths situated at
different parts of the bladder each one is caught at its base
with the haemostatic forceps, ti-eated, and cut off. Single

Fm. 67. — Bladder tumor drawn out through a Taeinal ini-'ision. The hariiDstiilic
elamp grasps the fiedicle; the Ehidil forceps is shown hj dotted lines lieyoiui
the olamp. The patient is in tliu Siins's postare.

lanje growths with broad attachments are ti-eated in sec-
tions; that is to say, a portion, such as can be grasped at
once with the forceps and treated, and then another, until
the whole is exsected. Long refractors are used to keep
the bladder walls away from the hot foi-ceps in cases where
there is not room enough to use the shield forcejis con-
veniently. Fig. 68 illustrates this part of tlie operation.

Wlien the disease has involved the muscular wall "f
the bladder (a condition found only in cancer) the entire

106

ELBCTRO-H.KMOSTASIS IN OPERATIVE SURGERY

base of the tumor, inclutliiig the bladdei- wall, should be
removed. That is done by first removing the tumor which
projects above the surface, then seiziog the stump in the
middle, and by traction drawing it inwaifl and upwai'd
until the haemostatic forceps can be applied and the whole

— A pedunculated, growth of tiie bladder clamped by the hwiiioctalic
forceps ; the VilaJder wuTi is prntected by the shiehl fortep^. On the anterior
bladder wall the stump of a prcvioualy treated tumor Is shown.

of the diseased part removed ; or, if that can not be done at
once, it can be done in sections. This radical treatment of
advanced cases should not be undertaken if the disease
involves or goes close to the ureters or urethra. In the
majority of cases the bladder should be drained from

EXTIRPATION OF TUMORS OF TOE BLADDER. 107

above until healing is completed ; but if tlie bane aud
fundus aie noiuial the wound may be closed and drainage
made with the catheter.

The stumps are thrown off in course of the healing,
and should be waahetl out. Any scrap of dead tissue left
would form a nucleus for a calculus.

There being no hnemoiThage in operating in this way,
the [trocedure is easily accomplished compared with the
old way.

The wounds left to heal are very small, and the stumps
being glued together, as it were, become almost completely
healed before the desiccated portions are thrown off. It
may be said that the bases from which the tumors were
removed heal under a scab, thus avoiding ulcerating sur-
faces that are slow to heal.

By removing single small neoplasms in this way the
opening in the bladder can be closed immediately, and the
treatment completed in one ojieration. The thoroughness
of the operation prevents or delays the recurrence which
followed sooner or later in all my cases treated according
to other methods. The follo\viug ease selected from a
number illustrate the clinical history and treatment of
this class of affections:

Mrs. H. H, C. came under observation in January, 1892,
saying that for some little time past, following convales-
cence fix)m a severe attack of la grippe, she had been notic-
ing blood in her urine. At first but little attention was
given to this condition for she never suffei-ed any pain ;
but dnring the past six months she Iwcame aware of feel-
ing easily fatigued, and felt that she was " running down " :
at the same time the h^raatnria was becoming more and
more pronounced, untU for the six weeks prior to her arl-
mission the urine constantly ebowed the jn^sence of large
amounts of blood.

The haemorrhages were at once controlled by inigations
with acetic acid and the administration of instillations of
fifteen drops of fluid extract of hydrastis canadensis before

108 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

meals. In a few days a thorough cystoscopic examination
could be made. The bleeding was traced to a papillo-
matous growth in the upper left lateral quadrant of the
bladder. The tumor was removed on January 28th, by
way of the vagina, with the clamp and cautery. The
fistula was closed at once.

The recovery was favorable. Some large granules of
phosphates were found in the urine for a few days after
the operation. When the sutures were removed in the
following week the fistula had closed, except a small open-
ing of the mucous membrane of the vagina in the lower
angle. This was obliterated within the week, and the pa-
tient left the sanatorium nine days later.

In the fall of 1894 the patient returned with a history
of entire relief until a few months ago ; but that now her
urine again shows some color almost constantly, and at
times is decidedly bloody. She has been well otherwise
except for a severe siege of typhoid fever, but this did not
seem to have any influence upon her bladder. She is free
from pain, retains her urine the usual length of time, and
feels just as she did at the time of the previous operation.

The cystoscope shows a possible return of the neoplasm,
but the area is darker in color and. looks more like a deposit
of urine salts on the scar. The examination was not entirely
satisfactory, as there had been bleeding the day before ; so
the bladder was irrigated and prepared for another exam-
ination. This time the cystoscope reveals several neoplasms
near the fundus ; they are smooth, lobulated, of a grayish
color. There is also a body in the base of the bladder,
round and like a stone, but it does not give the character-
istic click when touched with the sound. When the blad-
der was opened this area was found to be a deposit of
urinary salts on a soft papillomatous base. A suprapubic
cystotomy was done, and a number of small papillomatous
tumors removed by the new method. The patient was dis-
charged after an uneventful recovery.

Six years after the first operation the patient once more

EXTIRPATION OF TUMORS OF THE BLADDER. 109

returns for relief. But this time the history is very diflfer-
ent. She has been in almost constant pain for a year. At
times there would be a temporary amelioration of her con-
dition, but for the greater part of the period she has been
most at ease only when lying on her back. Micturition
has been normal, but frequent, and at times would be pre-
ceded, again followed, by sharp spasmodic pains. The his-
tory is meager as to the appearance and character of the
urine. It is thought that two small gravel stones were
voided in the fall of 1896, yet the diagnosis of calculus was
not made by the physician in charge. The case was treated
as simple catarrhal cystitis. The only other important inci-
dent observed was an occasional incontinence.

A vesical calculus was discovered at once, and the diag-
nosis confirmed February 15, 1898, by doing a vaginal
cystotomy and removing a large stone. The weight is
fifty-six grammes ; it is fifty-five millimetres long, thirty-five
millimetres wide, and one hundred and ten millimetres in
transverse circumference. The shape is that of a slightly
irregular ovoid flattened at one of the poles, and is fairly
smooth. On section only a few lamellae are seen, and these
are toward the periphery. The nucleus is distinguished
from the rest only by being imbedded in a deeper mass of
more porous matter. Chemical analysis places it in the
class defined by Hoffman and Ultzman as " metamorphosed "
stones, for it is coiriposed of earthy phosphates forming a
quite homogeneous and porous mass.

Convalescence was rapid; there was no return of the
pain ; and the urine showed a rapid decrease in crystalline
deposit and the usual evidences of bladder irritation caused
by a calculus. The wound was left open to insure perfect
drainage for a time. It would have closed of its own ac-
cord had it not been for a prolapsus of a portion of the
mucous membrane into the lower angle of the opening.

The after-treatment has consisted in daily irrigations,
and for a week maintaining continual drainage during the
night by catheter. Within a fortnight the patient was

110 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

able to sit up several hours daily without any discomfort
or any return of her former ill feeling or symptoms, and
about a month after the operation returned to her home.

The interest in the case centers largely in there being
no recurrence of the former growths, in the age of the pa-
tient (she is now sixty-three years of age), in the size of
the stone, its rapid formation, and that its formation was
due to some scrap of dead tissue that remained after the
second operation.

After remaining at home for two months, during which
time she was well and regained her strength, she returned,
and I closed the small fistulous opening that remained.
Before operating to close the fistula a most rigid examina-
tion of the bladder was made, but no foreign body was
found, and not the slightest evidence of a recurrence of the
papillomatous growths. It is now nearly a year since she
went from under my care, and she is perfectly well in
every respect.

THE TREATMENT OF ULCERS OF THE BLADDER WITH THE

GALVANO-OAUTERY

I was induced to use the galvano-cautery in the treat-
ment of ulcers in the bladder by a somewhat curious expe-
rience.

A girl nineteen years of age came to my clinic suf-
fering from hsBmaturia, which had troubled her for over
two months. Her health was good and the urine normal,
excepting the blood which it contained. I first made sure
that the blood came from the bladder, and then put her
upon the usual internal remedies for haemorrhage of the
bladder, but with no benefit to her. A bimanual examina-
tion of the bladder gave negative evidence, but it increased
the haemorrhage for a time. A solution of acetic acid,
which was used to wash out the bladder, controlled the
bleeding long enough for a cystoscopic examination. On
the lower part of the posterior wall I found a whitish-gi'ay
colored body about three eighths of an inch in diameter,

EXTIRPATION OF TUMORS OP THE BLADDKR.

surrounded by a boi'der of papillomatous or granulation
tissue very red and vascular, A diagnosia of calculus
partially encysted was made upon the physical signs ob-
tained with the eystoscope. The use of the sound and a
bimanual examination gave no evidence confirmatory of the
diagnosis. The bladder was opened through the vagina,
and I found that the object which appeared to be a stone
was a thick deposit of urine salts upon an ulcerated sur-
face. The deposit and soft vascular tissue around it were
removed with a curette and pressure made upon the raw
surface with a sponge until the bleeding ceased. A small
galvano-cautery was applied — at dull red heat — to the
whole surface long enough to destroy the whole of the
diseased tissue and form a thin dry crust over all.

The wound in the vagina was closed, and the bladder
drained with a catheter for three days. After that the
patient was made to urinate every four hours for the re-
mainder of the week. About that time a number of black-
ish pai-ticles were j'assed with the urine — the debris of the
cauterized tissue. For several days thereafter the bladder
was washed out to make sure that no bits of dead tissue
remained to cause the formation of a calculus.

The patient made a good recovery, and was well a year
later, at which time slie was and gave promise of continu-
ing free from recurrence of the affection.

The benefit derived from the cauterj' in this case in-
duced me to employ the same treatment in cases of ulcera-
tion of the bladder. In chronic cystitis of hmg standing,
especially in aged women, an ulceration occasionally occurs
generally at the base of the bladder. These are seldom
cured by instillations or caustic applications. This was
another inducement to try the cautery. Tlie diagnosis and
the localization of the ulcer is made with the eystoscope.
The operation or application is made by placing the patient
in the knee-chest position, introducing the largest endo-
scope that can be used with safety, and bringing the dis-
eased part into the field of vision and applying the cau-

112 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

teiy. Ulcers of considerable size can not be all seen at
once, and so one requires to cauterize portions at a time,
doing one part and then another till the whole is treated.
Considerable experience and practice is necessary in order
to operate successfully, but the benefits derived compensate
fully for all that.

CHAPTEK XII

THE ELECTRO-CAUTERY IN THE TREATMENT OF URETHRAL

AFFECTIONS

The diseases of the urethra in which the electro-cautery
is most effective are neoplasms about the meatus, urethritis,
narrowing of the meatus, either congenital or acquired, and
inflammation of the urethral glands and follicles.

In regard to the pathology of these neoplasms at the
meatus urinarius, there are two forms to which I wish to
call attention. One, the rarest, is angioma^ caused usually
by malnutrition and deranged circulation. These growths
closely resemble rectal haemorrhoids in both the pathology
and the causes which produce them. The other is a pro-
liferation of tissue, caused by a chronic inflammation of the
glands or follicles in the vaginal side of the urethra.
Both varieties have been known as vascular growths of the
meatus or caruncle.

The diagnosis is of course easily made when the dis-
ease is conflned to the exposed portion of the meatus, but
when these growths are within the urethra the diagnosis
can be made only by the use of the endoscope. I may
state in passing that many do not use this instrument for
diagnostic purposes, ovring to its being rather inconvenient
and requiring experience in its use. To meet that, I find
in many cases a diagnosis can be made by exclusion. Dis-
placements and dislocations can be detected or excluded by
the touch and sound, and cystitis can be disposed of by fi'e-
quent and careful urine examinations.

Most important of all in this connection is the cysto-
us

114 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

scope, which is so valuable in detecting or excluding dis-
eases of the bladder which simulate in a marked way cer-
tain diseases of the urethra, but this instrument is not
always at command. I find that the differential diagnosis
must be made by the majority of practitioners, if made at
all, by examinations of the urine and from the symptoms.
When it is determined by exclusion that the disease is con-
fined to the urethra, the question rests then between inflam-
matory affections and displacements and dilatation. The
latter can be detected, as before stated, by the touch and
sound.

To return to the treatment of neoplasms, the indications
are to thoroughly and completely destroy the diseased tis-
sue and nothing more. To do this with caustics in the way
usually commended is impossible — at least I find it so*
The diseased tissue can be destroyed, if not by one, by
several applications ; but the line of demarcation between
the normal and abnormal tissue can not be clearly and accu-
rately drawn, and the action of the caustic limited to that
one part. After the eschar separates the surface left to
heal is large, painful, and tender, and during the healing
process there is great liability to the recurrence of the orig-
inal disease. This is one of the reasons for the frequency
with which these growths return, as noted by all writers on
the subject. Exsection is a more surgical method which
gives better results when well done than caustics ; but un-
less sutures are used to close the wound the healing is slow
and uncertain, especially if the urine is in any degree
morbid.

The galvano-cautery fulfills all the requirements per-
fectly and completely. There is less pain in its use. Heal-
ing is more rapid, and there is less likelihood of the disease
returning.

The cautery instrument which I employ is the fine point*
(See Fig. 75.)

A larger cautery can be used with advantage in remov-
ing large neoplasms, but for all general purposes the small

TREATMENT OF URETHRAL AFFECTIONS.

one is tlie best. I may here mention the fact that it should
be brought to the desired heat before applying It to the
tissues, and then after making one incision or application it
should be withdrawn from the tissues and reheated. This
is necessary, because the moment this fine point is brought
into contact with the tissues there is so much leakage of
the current that the cautery very soon cools off a little. I
mention this because I have so often seen the inexperienced,
who were not aware of this fact, bothered by the cautery
cooling and not doing its work fast enough.

The method of operating for angioma at the meatus
urinarins is as follows :

The neoplasm to be removed is seized by narrow-liladed
forceps at the junction of the normal and abnormal tissue ;
the forceps is closed and locked and the neoplasm cut off.
The current is turned on and continued to heat the forceps
enough to desiccate, not char, the tissues in its grasp. When
this is accomplished the forceps is carefully removed by
first unlocking it, then rocking it gently, so as not to pull
the pedicle or stump apart and start bleeding. If the work
is well done, the thin stump of desiccated tissue will pro-
ject from the surface of the mucous membrane. If there
is any jiortion of the diseased tissue left, it should be
touched witli the cautery.

It is important that the patient should not urinate for
several hours after the operation, because if the stump can
be kept dry for a time it will not spread but hold together,
and leave a very small sui'face to heal when the desiccated
portion separates. The application ()f stearate of zinc helps
to protect the stump until it heals.

The forceps which I nee is like the compression forceps
but with very naiTow blades.

This method of operating is sufficient in the ordinaiy
forms of angioma. When the neojilasm is caused by a
chronic inflaniniation of the ui-ethral glands, the best method
is to pass a fine probe up into the canal and cut downnjxm
it with the cautery point from the vaginal surface ; in other

lltl ELECTRO-U.ICMOSTASIS IN OPERATIVE SURGERY.

words, lay the ducts of the glands open. This divides the
neoplasm on one side, and an incision should iie made with
the cauteiy on the opposite side, which divides the neo-

Fjo. hi*.— Operatioji upi
the gland: " "
the probe.

plasm into two equal parts ; then each part is grasped in
the forceps and removed in the way I described in the
treatment of angioma. The method of treating the disease
of the urethral glands is illustrated by Figs. 69 and 70.

I have succeeded in completely curing the chronic in-
flammation of the glands by laying their ducts open in this
way and removing the neoplasms at their terminal ends,
excepting in a few cases where the inflammation still per-
sists in the glands. To correct this I generally do a second
operation. I pass the cautery point into the gland and
cauterize it sufficiently to destroy it. I have succeeded in

TREATMENT OF URETHRAL APPECTIONS.

117

caring all cases in this way, except in tuberculosis of tlie
urethra. That disease has continued when tlie upper por-
tion of the canal was involved before operating.

The method of operating in cases of narrowing of the
meatus nrinarius is this : I pass a bivalve speculum into
the urethra and put the meatus on the stretch. The band
of tissue below or on the vaginal side which extends from
one blade to the other is made tense, and is easily divided
with the cautery ; in fact, it is necessary to be deliberate in
making the incisiou, or else haemorrhage will foUow ; not a
haemorrhage which will give any trouble except delay, as it
prevents continuing the use of the cautery to complete the
operation.

In cases of papillae withiu the urethra, caused by hyper-

Fid. 70. — The incision gapes after sptining open the gland.

plasia around the follicles, the treatment with the cautery
la difficult, but if properly employed gives the most jjrompt
relief iu those cases (tf chronic inflammation which have
been called granular urethritia. After having made a clear

118 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

diagnosis and localized the points to be destroyed, I intro-
duce the endoscope with an open end, up as near to the
neck of the bladder as can be without permitting a flow of
urine ; the instrument is then withdrawn until one of the
points to be touched comes into the field of vision; the
cautery is then passed up, and the point slowly touched
once, which is, as a rule, sufficient. The endoscope is then
again withdrawn until another diseased portion appears,
which is treated in the same way, and so on until the treat-
ment is completed.

IRRITABLE ULCER OF THE NECK OF THE BLADDER

The most troublesome of all diseases of the urinary
organs, both in the way of causing suffering to the patient
and botheration to the surgeon, is this ulcer or fissure at
the junction of the urethra and bladder.

The first difficulty is in making a diagnosis. In fact, I
have never been able to fully expose a fissure in the loca-
tion except with the glass endoscope, and I have tried all
other instruments in use. The treatment also is difficult.
When the fissure is exposed by means of an endoscope open
at the distal end there is a continual oozing of urine, which
interferes with the use of the cautery. If the fissure is on
the vaginal side of the urethra, this is obviated by using a
fenestrated endoscope and bringing the fissure into the field
of vision, while making pressure against the endoscope from
the vagina with the finger, to force the diseased portion of
the mucous membrane into the fenestrum and prevent the
outflow of urine. I then dry the part with a small piece of
bibulous paper, and apply the cautery by simply drawing
the point slowly through the ulcer so as to completely
destroy its surface.

To a certain extent lateral fissures can be managed in
the same way, but when the fissure occurs above, which
fortunately seldom happens, it is almost impossible to em-
ploy this treatment. Perhaps when I have had more ex-
perience I may be able to report quite favorably of this

TREATMENT OP URETHRAL AFFECTIONS. 119

treatment. Up to the present time it is not completely sat-
isfactory, though the best that has been obtained so far in
treating those forms of urethral aflEections already alluded to.
I find that with the use of cocaine general anaesthesia is
not necessary, at least in patients who possess a fair degree
of self-control, but I should advise the use of an anaesthetic
until the surgeon has acquired some skill and dexterity in
the management of the endoscope and the cautery.

CHAPTER XIII

ELECTRO-H^MOSTASIS IN THE TREATMENT OF RECTAL

HEMORRHOIDS

The clamp and cautery was used for a long time in
operating for haBmorrhoids, but the results obtained were
not altogether satisfactory. The clamp spread out the
tissues so that a broad stump was formed, and after re-
moving the clamp the tissue of the stump separated, leaving
a broad surface to heal. Bleeding was often caused by the
action of the bowels unless confined for a long time, and
healing was retarded.

These unfavorable conditions were avoided to some
extent by using a clamp with broad jaws, and after cutting
off the hsemorrhoid, applying the cautery to the forceps
long enough to desiccate the stump in the way that Keith
treated the pedicle of ovarian tumors. This required alto-
gether too much time, and it was so difficult to avoid too
much or too little heat that I became discouraged and re-
turned to. the ligature until the introduction of the haemo-
static forceps. Since then I have adopted that method,
and practice it exclusively.

In the preparatory treatment plenty of time should be
taken to get the digestive organs into the best possible
condition. If the tongue is coated and the appetite im-
paired, small doses of mild chloride of mercury should be
given, followed by a cathartic. A laxative should be given
in the evening before the day preceding the operation, so
that the bowels shall move in the morning, and at night

130

TREATMENT OP RECTAL H^MORKHOIDS.

before the operation the rectum should be washed out
thoroughly.

The sphincter is slowly stretched with a bivalve spec-
ulum to a degree sufficient to temporaiily paralyze the
muscle, but not to tear its fibers or lacerate the hemor-
rhoidal veins if possible. The most prominent hasmon'hoid
tumor is caught with a Peau forceps and drawn outward
(see Fig, 72, A), the haemorrhoidal clamp is applied to its
base, and the electric heat continued until desiccation is com-
plete; this requires from half a minute to a minute, rarely
more than half a minute, unless the tissues are very large.
A shield foi-ceps with shields of horn, tortoise shell or

istatie liicmorrhoidal clanip.

ivory, similar to the shield forceps used in ovariotomy, is
placed under the clamp to protect the tissues while the heat
is being applied.

The clamp (see Fig. 71) is made on the same prin-
ciple as the ovariotomy clamp described in the chapter on
ovariotomy, but is much smaller.

Fig. 72, B, shows the clamp in place parallel to the
axis of the canal while the cuirent is being useil.

Fig. 73 shows the clamp opened just enough to per-
mit the stump to escape from its grasp.

Fig. 72, C, shows the stump after treatment ; the long

122 ELECTRO-RSIMOSTASIS IN OPERATIVE 8DEGBRY.

measurement is in the axis of the canal, as it should be, in
order that it may rest in the folds of the mucous membrane
when the sphincter contracts.

During the process of repair the stump becomes soft-
ened by absorption of moisture, and part of it, at least,
separates and comes away, but not until the base has com-
pletely healed. The reader will observe that a stump ex-
posed on a free surface is not reorganized as is a stump
inclosed in the abdominal cavity or in cellular tissue. It
appears that the portion of the dried stump joining the liv-

Pro. 72. — A, the hwmorrhoid is dravn outward by a forcepB ; B, the hfemostatic
clamp and shield forceps in poaitioti while the current is being used ; C, the
stnmp after treatment ; the long measurement is in the axis of Uie canal.

ing tissue may become oi^anized during healing, but the free
end separatee and is thrown off as stated above. The

TREATMENT OF RECTAL H^MORRBOIDS. 123

mucoua membrane remains tender at the site of operation
until the process of repair is complete, therefore the parts

Fio. 73. — The clamp has been opened to pannit the Btump to escape from its grasp.

are easily torn open by distending the sphincter out to any
great extreme. On that account the bowels should be kept
at rest for several days after oiieration.

Owing to the stump in its greatest length running par-
allel to the axis of the rectum, it is in the position most
exposed to being opened up when the bowels are evacuated.

Dr. R. L. Dickinson suggested that the danger of open-
ing up the stumps might be guarded against by applying
the clamp at right angles to the axis of the rectum, or
rather he suggested that it should be made obliquely. (See
Fig. 74.) The effect of distending the sphincter would be
to draw the edges or sides of the stump more closely to-
gether, not to pull them apart. This appeared to me to be
a valuable su^estion, and I shall try it, taking care to liave
the stumps all outside of the grasp of the sphincter when
the location of the hemorrhoid is such that this can be

124 ELECTEO-H^MOSTASIS IN OPERATIVE SURGERY.

done. That ie to say, I shall form the stump at the junc-
tion of the skin and mucous membrane.

Aftei'-treatmerU. — The parta are dusted with dry, finely
powdered bicarbonate of soda or subgallate of bismuth,
applied with the insufflator.

The patient is kept at rest for a week or ten days, and
liquid diet given — sonps, broths, and gruels being preferable
to milk.

As this operation is followed by much less pain than
when the ligature is used, opium is seldom required. When

Fio. 74. — Diagrams of scars or stumps after removal of piles, and the strains ap-

head operation partly sutured, circular line of uuion. The stresses are two^
longitudinal, in the axis of the anus ; and tranm.'eTW, at right angles to that
axis. The longitudinal stress, shown by the stumpy airoirs. and produced by
the shoving onward of the mucous membrane or skin about the anus as a
IsxaX mass makes exit, can have little hurtful effect on A. and much on C.
The transverse tension, produced by stretching of sphincter by ftecal mass,
shown by the longer curved arrows,'does no harm to C. but great hurt to A.
The oblique bit«, B. is least likely to be hurt by the combined strain, — Brook-
lyn Medical Journal, vol, xiii, No. 1, p. 54, January, 1888.

called for, I use liquor opii corap. and tincture of belladonna,
instilled into the rectum with a soft catheter or pipette.
The bowels can be safely moved on the second or third day,
but it is better to keep the patient on spare liquid diet,
and wait until the fourth or fifth day. On the evening of
the fourth day a small laxative dose of pulve. glycerrhiza
comp. is given, and followed in the morning with a dose of
phosphate of soda and two hours later an enema of flax-

TREATMENT OF RECTAL HEMORRHOIDS. 135

seed tea. The flaxseed tea is the most agreeable and eflicient
eoema in all rectal diseases when this aid to action is re-
quired. After the bowels are evacuated the |tart9 should be
thoroughly cleansed by in'igatiou, then dried with absorb-
ent cotton, and the subgallate of bismuth powder employed.
The bowels are peimitted to rest for one day, and after that
they should be moved each day. Some of the best author-
ities permit their patients to sit up in about three days,
and in about a week they are allowed to go about ; but I
am sure that this is not the best after-care. It is better to
keep the patient quiet until healing is complete, which re-
quires about ten or twelve days. It is claimed that pa-
tients treated in the old way are able t(j be uji ami at Inisi-
ness in a few days, but better results are obtained by taking
more time.

Finally, complete recover^' takes place in less time than
after any other method of operating that I have ever known.

FISSURE OR IKKITABLE ULCER AT THE TERMLNAL END OF
THE RECTUM

To comprehend the treatment of this affection mth the
galvano-cautery it is necessaiy to undei-stand its true pathol-
ogy and causation, especially the latter. Van Biireu gives
such a graphic descrii>tion of that disease that I prefer
to quote in ioto : " There is no disease to which Immanity
is liable — certainly none so insignificant in extent — which
is capable of causing more intolerable suffering than the
ailment generally known as fissure of the anus. It is more
properly styled irritable ulcer of the rectum, for this desig-
nation describes accurately the true pathological nature of
the disease. The ulcer originates in a fissure or crack in
the delicate integument lining the orifice of the anus, or, to
speak with greater exactness, in the mucous membrane just
about assuming the character of skin wluch lines that por-
tion of the rectum erabi'aced by the sphincter-ani muscle.
Doubtless there are cracks and fissures occuning frequently
in this exposed locality, under the influence of costiveness

126 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

and violent stretching, which get well promptly without
their existence having been suspected; and others again
which last a longer or shorter time, and give but little
trouble. But in certain conditions of the system, and where,
under the necessity imposed by habitual constipation, this
forcible distention is repeated daily, the fissure fails to heal
promptly ; and then, as under all similar circumstances of
constantly repeated mechanical irritation, inflammation de-
velops itself in the little wound, and just in proportion as
the inflammation advances the effort at repair diminishes,
until finally it ceases entirely. The solution of continuity,
or ulcer as it is now, being still exposed to constantly recur-
ring mechanical violence and to the contact of chemically
irritating substances, is kept thus in an actively inflamed
condition and soon puts on all the features of an irritable
ulcer."

Van Buren's description is complete, perfect, and accept-
able in all respects, except that the causation given is not
fully in harmony with the clinical facts as I have observed
them. The actual cause of the persistence of certain fissures
is that they extend outward from the mucous membrane
to the skin, and a small pocket is formed beneath the skin
in the terminal end of the fissure. That portion of the skin
overlying the lower end of the fissure in the mucous mem-
brane becomes indurated and stands outward so that the
pocket remains open and filled with irritable substances,
which prevent the parts from healing. Fissures wholly in
the mucous membrane and not having this pocket heal
promptly.

Fig. 75, Ay shows a sketch of the anus with the fissure
and pocket.

The diagnosis is completed by a physical examination.
The books direct that the parts should be separated and a
slight inversion produced, which brings the ulcer or part of
it into view. It is possible to do this when the sphincter-
ani muscle is relaxed, but it is generally contracted, and the
patients resist the efforts to bring the lesion into view.

TREATMENT OF BECTAL HEMORRHOIDS. 127

The most satisfactory examination is with the glass endo-
scope. In fact, that is the only instrument with which anal
fissures can be clearly seen. The glass tube distends the
parts sufficiently to lay the fissure open and bring it fully
into view, and its use causes no suffering on the part of the
patient and is far more agreeable to the surgeon than rectal
specula or endoscopes in general use.

rsTfcT]

The treatment consists in applying cocaine to the ulcer
by means of a pipette, a small Sims speculum is introduced,
and then I lay open the pocket at the most dependent part
of the fissure with a fine cautery point. (See Fig. 75, _B.)
This exposes the entire ulcerated surface, which is then

128 ELECTRO-II^MOSTASIS IN OPERATIVE SURGERY.

cauterized throughout, but only superficially. The cauteri-
zation should include the indurated edges of the ulcer, but
should not be carried deep into the mucous membrane ; only
far enough to destroy the diseased tissue. No after-treat-
ment is required. The charred tissue protects the parts
below until healing has been completed.

The treatment is not suflSciently painful to require gen-
eral ansBsthesia, and relief from suffering is almost immediate.
The ultimate results are quite as satisfactory as the old
treatment by stretching the sphincter to divide the fibers of
the sphincter beneath the fissure.

The following case recently treated is typical of many
that I have relieved in the same way : This patient became
constipated after the birth of her third child, and about two
months after that confinement began to have all the symp-
toms of fissure of the anus. Her physician gave her oint-
ments and suppositories of various kinds to use, and treated
successfully her constipation, but she obtained no relief
from her rectal pain. After three months of suffering her
health became impaired and a surgeon was called in consul-
tation who made a diagnosis of fissure, and advised oper-
ative treatment. This proposition was accepted by the
patient, but her husband was fearful of anaesthetics, so he
brought her to my ofiSce. The history was fully given, in-
cluding the fact that she had been treated with local appli-
cations, but finding no relief had given up. No mention
was made of the proposed operation. A well-developed
irritable ulcer was found, and I suggested immediate treat-
ment, and the patient agreeing, I operated there and then.
The patient told me that I caused less pain than the exam-
ination made by the surgeon who had j)reviously seeti her.
When I asked her why she had not told me about that, she
replied that she wished to find out if I would advise the same
treatment or something else that would relieve her without
having to take an anaesthetic. Her recovery was perfect.

CHAPTER XIV

THE TREATMENT OF NEOPLASMS OF THE SKIN AND MUCOUS
MEMBRANES WITH THE ELECTRO- CAUTERY AND ELECTROLYSIS

My attention has been called to this subject especially
by seeing three patients who were treated a long time ago,
one with electrolysis and two with galvano-cautery. The
results were so very satisfactory that they recalled many
other cases equally complimentary to this method of treat-
ment. One of the three cases was a nevus situated between
the eyebrows of a child five months old. The skin cover-
ing the elevation was of a bluish red for about half an inch
across, and three quarters of an inch vertically. The tumor
disappeared on pressure, showing that the enlarged vessels
were mostly in the cellular tissue. It was growing very
rapidly. Electrolysis was employed, and that child is now
a boy fourteen years old, with no trace of the nevus or the
treatment to be seen. The second case was one of epithe-
lioma of the lower lip of a lady. She was examined by a
surgeon of reputation, who advised its removal. I fully
confirmed the diagnosis by clinical and microscopic exami-
nation, and removed the growth with the galvano-cautery.
It is now four years since that operation, and there is no
deformity of the lip nor any trace of the disease. The third
case was nevus pilaris, or hairy papilloma on the cheek.
This was removed with the cautery, and there is only a small
speck of scar tissue, which is barely visible on close inspec-
tion. A hundred or more cases to illustrate the results of
this mode of treatment might be given, but these will suf-
fice to bring the subject to the attention of the reader.

129

130 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

Excepting in vascular tumors, in which the large vessels
are subcuticular, and in which it is desirable to preserve
the skin covering the vascular growth, the galvano-cautery
best answers the purpose in all cases. In the exceptional
cases electrolysis gives the best results. Skill and accuracy
in operating are very essential. The needles should be
round-pointed, so that they may close their tracks and pre-
vent bleeding. They should be insulated to within a dis-
tance from the point nearly the length of the diameter of
the tumor. This enables the operator to bring the acting
part of the needle into contact with the tissue to be de-
stroyed, and yet preserve the normal skin at the point of
puncture. The electric current used should be strong
enough to produce chemical decomposition at the negative
and desiccation or cooking, but not charring, at the positive
needle. These changes in the tissue are manifested by its
becoming hard, especially along the line of the positive
needle, which becomes immovable by sticking to the tissue.
When these changes have taken place the current should be
reversed and continued until the positive needle becomes loose.

If the needles are withdrawn without reversing the
current, troublesome haemorrhage follows and interrupts
the treatment. If there is no disposition to bleeding when
the needles are partially withdrawn, they should be re-
moved and again introduced into the parts of the tumor
remaining unaffected, and the current used as in the first
instance. In medium-sized tumors the treatment can be
completed by two introductions of the needle, but if any
part escapes, as shown by the soft condition due to the
circulation continuing in some of the vessels, the procedure
should be repeated. The needle punctures on the surface
should be closed vnth collodion to prevent the entrance of
anything that might cause suppuration. Usually repair
goes on favorably along with the absorption of the de-
stroyed tissue. If suppuration takes place the pus should
be washed out through the needle punctures, and drainage
kept up with a few horsehairs or some twisted silk

NEOPLASMS OP THE SKIN AND MUCOUS MEMBRANES. 131

The galvauo-cauteTy, certainly, so far as resultB are con-
cerned, is iufinitely tte best method of removing neoplasms
from the skin and mucous membranes, excepting in such
cases as just mentioned. When properly employed it
causes less pain during the operation, the recovery is much
more prompt and complete, and the scar tissue that follows
is veiy much less in extent than by any other method of
dealing with these growths. The objections to the various
forma of caustics, such as nitric and chromic acid, are that
they do not completely destroy the tissue ; that they cause
very much more pain and sirffeiing ; that they are not so
certain in their results ; and that they leave far more un-
sightly seal's.

That which comes the nearest to the galvano^autery is
the paste of chloride of zinc, lactic acid, and caustic potash.
These have been employed by Dr. I. N. Bloom, of Louis-
ville, Ky. Of any results with which I am familiar his
apjiroach most nearly those obtained by the galvano-cautery ;
but they fall short of accomplishing the objects that are
obtained so thoroughly and completely by the use of the
galvano-cauteiy. Considerable practice is necessary to ac-
quire facility in technique.

The great object is to thoroughly destroy the diseased
or abnormal tissue with the cautery at a degree of about
red heat, and, while destroying all that is abnormal, not
to go beyond the boundary line or encroach upon the
normal tissue. It is very important, especially in vascular
growths, to apply the cautery to the tissue to be destroyed
before turning on the heat. If it is heated and then ap-
plied, there is very great danger of htemorrhage, especially
iu vascular tumors. A small cautery point should be used,
unless the growth is very large, and it is most convenient
to place it into the center of the mass to be destroyed while
it is cold. The heat being turned on, the cauterization or
destruction of the tissue should proceed from the center
toward the cii-cimiference, so as to make it complete with-
out going beyond the boundary of abnormal tissue. It is

132 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

always well not to go too deep at first. If it is found
that there is still some diseased tissue deeper down, the
ground can be gone over again until the destruction is com-
plete.

In operating upon small tumors about the mouth, cheeks,
or forehead the parts should be held perfectly to prevent
twitching of the muscles. Neglect of this may cause the
cautery to slip and injure the normal skin and lead to un-
necessary scars.

In angioma, nevus, and epithelioma, especially when the
mass or growth is large and vascular, it is better to begin
at the circumference and work toward the center, always
using the cautery at a dull-red heat, since if the heat is too
great — that is, white heat — ^there is sure to be bleeding.
In fact, in cases of angioma it is impossible sometimes to
operate in this way without having very decided haemor-
rhage. In such cases I have adopted another method which
answers very well, and that is to seize the mass with a
haemostatic forceps in the central portion or where the ves-
sels are largest, and strongly compress it, then turn on the
electric heat, and desiccate it before letting go. This will
control the bleeding in the larger vessels, and then with the
cautery point the rest of the tissue at the outer margins of
the growth can be destroyed in the way already described.
That method of operating can also be done in cases of epi-
thelioma, but the results are not quite so satisfactory, be-
cause the friable tissue breaks down in the grasp of the
haemostatic forceps and so can not be controlled in that
way ; but in small vascular growths the results are very satis-
factory in operating as described.

This method is equally applicable in case the part
operated upon be mucous membrane or skin. Where the
diseased part is located on the mucous membrane, say of
the cervix uteri, the lip, the tongue, or any portion of the
mouth, the pain is slight, and in the most sensitive cases it
is only necessary to use a little cocaine to be able to oper-
ate without causing any great distress. Indeed, this is the

NKOl'LASMS OF TUB SKIN AND MUCOUS MEMBRANES.

most painless method of operating, as it causes much less
pain than any caustic or paste that I knoi,v anything about
In fact, it ia not necessary to employ au anaesthetic except
in lai^e epitheliomatous gro\vthB about the face. The most
sensitive patients usually tolerate well the operation any-
where on the skin, unless the growth is unusually large. In
case one fails to remove all the diseased tissue, which some-
times happens, it is veiy easy to make a second application
after the healing process has been completed and the eschar
has separated and come away, which usually hapj)ens at the
end of a week.

The condition of the parts when the operation has been
well done is simply this : All the tissues are burned away
or destroyed, and the surface is covered with a thin layer of
charred tissue, which shows as a black mark outlining the
extent of the original tumor. A few hours after the treat-
ment the mucous membrane or skin around the cauterized
portion becomes quite red, but this redness passes off by the
following morning, or sometimes very much sooner; and
then all that remains to indicate the field of operation is the
spot of charred tissue, which is not by any means unsightly.
There is, of course, no dressing necessary-. The char forms a
perfect crust, under which the tissues heal kindly and very
quickly. It is needless to say that the ojwration is aseptic,
and hence there is no way by which any pathogenic germs
can be left in the wound to set up inflammation. This
probably accounts for the rapid healing, as in about five or
six days the charred tissue usually separates, comes away,
and leaves a red surface which requires no further cai'e.
When the charred tissue separates the surface is usually
completely healed, and differs from the suiTounding tissue
only in being of a deejier color. During the healing pro-
cess the parts contract, so that on the separation of the
charred crust the scar is very much smaller than it was at
the close of the operatifin. The redness fades away gradu-
ally, and at the same time the parts keep contracting, so that
in the course of time the scar is almost, if not completely.

134: ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

imperceptible. A scar of a magnitude that is noticeable is
left only in case the tumor is very large.

A point of interest in the management of nevi pilares,
that are so frequently seen on the face, is that in such cases
it is necessary to carry the cauterization deep down, almost
through the true skin, so as to destroy the hair bulb
completely. If one cauterizes only superficially, the hairs
will grow up again and no great benefit will result. The
cauterization should be carried down deeply into the center
where the hairs are, and then continued upward and out-
ward toward the surface, so that when the entire growth is
destroyed the cavity left is cone-shaped, the apex of the
cone being deep down in the skin. Cases treated in this
way do remarkably well, because this cone-shaped opening
contracts nicely and the results are finally very gratifying.
I have in mind at this moment a large number of such
growths on the face which were so treated. The great
point is to obtain complete, perfect results with the most
desirable cosmetic effect, and the least possible or no dis-
figurement from scars.

This method of operating gives vastly better results
than any other means at our command. From quite an ex-
tensive experience I know that the results obtained are
better than those with excision by means of a knife. In
operating with a knife it is necessary to make a long in-
cision and unite the parts with sutures, and the result
invariably is that the suture marks and a long scar are left.
This is the fact even if every precaution is taken, and the
best possible results are obtained in the way of immediate
union.

In case there is any suppuration, as may happen at any
time in spite of the utmost care to obtain aseptic conditions,
there will sometimes be a little failure of union, and an
ugly scar is left to annoy the patient. When the cautery
is used no dressing is necessary, as the cauterized or charred
tissue is itself by far the best dressing possible.

Again, if we compare the results with the caustics, such

NEOPLASMS OF THE SKIN AND MUCOUS MEMBRANES. I35

as nitric or clironiic acid, the advantages are markedly
apparent in that these invariably leave a very ugly scar that
does not disappear completely, and remains a glaring de-
fect for a long time to mar the beauty of the patient. The
same may be said with reference to the use of pastes, such
as already have been alluded to. They all leave very ugly
scars compared with the scar that is left, or the absence of
scar, as it might be called, when the cautery is employed.
This is one of the most important advantages of this way of
operating ; and it is not the only one, for the method has
advantages in every particular over all other known methods.
My attention was first called to the galvano-cautery in the
treatment of cancer of the uterus by my friend Dr. John
Byrne, and I have always felt grateful to him for his valua-
ble instruction. Dr. George M. Beard taught me how to
practice electrolysis in the treatment of vascular nevi, and
I desire to pay tribute to the memory of that gifted man
who was one of the first to develop scientific electro-thera-
peutics.

CHAPTER XV

ASEPSIS AND ANTISEPSIS IN SURGERY

Success in surgery depends upon cleanliness as well as
skillful and accurate operating, and in estimating one's work
the methods of obtaining aseptic conditions by means of
antiseptic methods must be taken into account.

Therefore I have deemed it expedient to give a chapter
on this subject to show the conditions under which my
operative work has been done. Much of detail has been
omitted to make room for that which is considered impor-
tant in the writer's practice.

Surgeons are fairly well united in their opinions regard-
ing the beneficence of the modern discoveries in bacteri-
ology, the germ causation of disease, and the inestimable
value of disinfection and sterilization as means of preven-
tion of surgical affections. Harmony prevails also to a
gratifying extent regarding the principles of aseptic and
antiseptic surgery. Still there is much diversity of opinion
regarding the methods of practical cleanliness in all opera-
tive work.

There are, indeed, many ways of trying to keep wounds
free from septic contamination and keeping them clean
during the healing process. In fact, there are nearly as
many methods as there are distinguished surgeons. The
aim and objects are the same with all, but the means by
which the results are obtained differ in detail very greatly.
The methods of asepsis in surgery were very complicated
at first, and they are still somewhat so. The tendency has
been toward simplicity, and in proportion to the discovery
of uncomplicated methods efficiency has been attained.

136

ASEPSIS AND ANTISEPSIS IN SURGERY. 137

The same light that revealed the part that germs play-
in the causation of disease, and that made clear the preven-
tion of all kinds of sepsis, led with equal scientific cei'tainty
to improvements in sanitarj' architecture or construction of
hospitala and homes for the wick.

In this department of hygiene and preventative medi-
cine the progress toward perfection has been so vast and
varied that volumes might be filled with the records.
Specialists in sanitary science, aided by skilled engineers,
intelligent, honest plumbers — there are such nowadays-
make the selection of proper sites for institutions for sick
and injured, and by faultless construction fulfill all the re-
quirements in foundations, ventilation, lighting, heating, and
draining. The recent improvements in this regard are well-
nigh perfect and quite familiar to all who take an interest
in the subject. The special efEorts now being made I'elating
to sanitary architecture are directed to facilitating disinfec-
tion and maintenance of cleanliness. This is more directly
related to operative surgery ; hence I may with propriety
note some of the improvements that have been j'ecently
made and especially connected with the subject now under
consideration. The first architectural principles in the
construction of rooms for the sick are to guard against
places for the accumulation of dirt and lodgment of dis-
ease germa

The best work on design and construction of institu-
tions for the care of the sick that I have seen any^vhei-e is
that of Marshall L. Emeiy, an architect who has taken
great interest in this branch of his art. Evidently he first
informed himself by consultation with medical men regard-
ing the requii'ements of a hospital and endeavored to meet
them. The following is taken from Mr. Emery's writing
on the Bubject :

SANrrART HOSPITAL CONSTRUCTIOW

A modem hospital, designed and arranged to meet mod-
em requii'ements, is the result of an evolution extending

138 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

over many years and embracing the conscientious labors of
many able investigators in both the medical and architec-
tural professions.

The progress in the science of medicine and surgery has
made from time to time new demands upon the architect
and the builder, and while a great many of these demands
have been fully met, there are some which require still fur-
ther study and invention in both the material and the mode
of construction. It may be assumed for present purposes
that the science of hospital planning is well advanced
toward the ideal; the size, shape, and sequence of the
various departments have been gradually reduced to a
typical or standard arrangement which is capable of being
carried out, and a satisfactory result obtained where space
and means are available. In the matter of constructive
detail, however, the requirements of modem medical science
are greater than can be provided by the means and methods
of building at present in use. This may be shown by taking
for example a single room, and as an operating room is
probably the most severe in its demands, it may be taken
as a type for all the rest, on the assumption that any detail
which meets the conditions in such a room will be satisfac-
tory in any of the others, though the matter of cost would
undoubtedly preclude the use of this construction through-
out the whole building.

An operating room consists, in common with all other
rooms, of the following parts : Walls, floor, ceiling, doors,
windows, sash, door- and window- jambs and casings and
base. All tlie matters of detail must conform to the follow-
ing principles : They must be hard, non-porous, durable, as
free from joints of any kind as possible, and free from all
sharp corners or angles, or any other feature tending to col-
lect dirt or septic matter, or offer any obstruction to its
ready and complete removal ; furthermore, they must be of
such a nature that they shall not change their size, shape,
or positions after erection, but shall remain as originally set
up — in short, they must not shrink, warp, or settle, or do

ASEreiS ANll ANTISEPSIS IS SURGERV. I39

any of the disagreeable tbiuge that building material is
constantly doing.

In some of the details the principles are easily lived up
to, and with some forms of construction and sufficient
means many of the demands can be complied with ; but
even at best^ there are some required features which present
material and building methods can not provide.

It might, of course, be possible, theoretically, to design
a room where all the conditions should be supplied, but
such a room would be a practical impossibility, owing prin-
cipally to its gi-eat cost and the difficulty of pi-ocuriug
sufficiently skiUed labor in its construction.

The greatest obstacle to be overcome lies in the almost
imperative necessity for the use of wood to a greater or less
extent, dei>ending upon the money to be expended.

We can beat proceed by taking up the details of con-
traction as already enumerated, beginning with the walls-
One or more of these will, of com-se, be an exterior wall con-
taining one or more windows. As the ordinary form of con-
struction suffices and is generally familiar, we shall discuss
but one feature, namely, that of insulation. All outside walls
have t.o be built to prevent condensation of the warm air of
the room, and to prevent loss of heat by conduction through
the material of the wall. This is generally accomplished in
one of three ways — building the wall so as to leave a h<dlow
Bi)ace in the wall itself of from two to four inches ; building
in the wall a course of hollow bricks extending from bot-
tom to top; or lining the wall on the inside with hollow
terra-cotta tile. In cheap construction wood furring strips
are useil to which the lathing is nailed, an air space being
formed thereby about e(|ual to the thickness of the fuiTing
strips, usually from one to two inches. Either of the first
three methods is good, and possiblj' the first the best, if
properly built ; though the terra-cotta tiles are most fre-
quently used.

The partition or interior walls may be of three forms :
Solid brick, rough, pressed, or enameled ; hollow brick, terra-

140 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

cotta tiles, or solid plaster cement ; or a light framework,
for high ceilings, long spans, etc. The solid brickwork is the
best ; but for small walls, or where walls are carried by the
floor construction or girders, it is generally more advan-
tageous to use one of the latter forms. The hollow tile
range from two inches to eight inches in thickness, and
average about sixteen inch squares. They are laid in mortar
in very much the same manner as common brick. The solid
plaster partitions have come into use within this last five
years, and have many advantages. They cost less than solid
brick or terra-cotta, and as they are but two to two and a half
inches thick they save considerable floor space. They are
lighter than brick partitions and do not require any spe-
cially heavy floor construction, but can be placed where de-
sirable without reference to beams and girders.

The floor construction is important, as the ceilings and
other matters depend largely on their stability.

If the money at disposal will allow, steel beams should
of course be used ; and if not, then Georgia pine beams of
large section and as free from sap as possible.

In the case of steel beams, the spaces between beams
may be spanned in various ways — either by several forms of
hollow-tile arches, or by a number of patented systems
consisting of a combination of iron bars or netting and con-
crete. There is little choice among the several forms for
hospital use. Where the loads on the floors are compara-
tively light, the cost is generally in favor of concrete and iron.
If wood beams are used, there should always be double
floors laid, with layers of water- and fire-proof material be-
tween them, unless a tile or other non-combustible flooring
be used. Tile, concrete, or mosaic floors are sometimes laid
on wood beams, but the result is bound to be unsatisfactory,
and the practice is to be avoided as far as possible. Should
it be necessary, however, it is accomplished by nailing cleats
to the sides of the beams two to three inches below their
tops, to which a rough floor is nailed. On this rough floor
is laid a bed of concrete to within about an inch of the

ASEPSIS AND ANTISEPSIS IN SURGERY. 141

finished floor ; this inch being left for the tile, marble, or
cement finishing surface. AsceOings are almost invariably
finished in plaster, it is only necessary in the ceiling con-
struction to provide a sufficiently strong and rigid foundation
to support the plaster. If steel beams be used, a system of
light iron framework is secured to the lower edges or
" flanges " of the beams, upon which wire or sheet-metal lath
is stretched and plastered.

In the use of wood beams the wire or metal lath is
nailed directly to the beams, or to wood fun-ing strips nailed
to them.

The flooi-s may be finished in either tile, marble, mosaic,
concrete, or wood block. The first three forms are all familiar,
and of these the tile is preferable, provided a hard " vitrified "
tile be used not exceeding two inches square, lai^er tiles
being apt to loosen. Hardwood blocks, about two inches
wide and twelve inches long, put down on a concrete foun-
dation with aB])haltic cement, have been used lately to some
extent, but as they cost neai-ly as much as tile or mosaic,
and have to be kept constantly " filled," waxed, or varnished
there seems to be little if any advantage in their use.

If necessary to use an orilinary woo<l floor, it should be
laid double, as already mentioned ; the upper flooring not
exceeding two inches in width, and of hanl, close-grained
wix)d, thoroughly seasoned, dry, and well nailed. The rr>ugh
or under floor should be laid diagonally across the floor
beams and the top or finished floor laid at right angles to
them. The top floor should be suKxtthed off and planed
over the whole surface, and "filled" and finished imme-
diately after.

Wood fliwrs are often laid on a fireproof construction
by bedding wood sleepers two inches thick on the steel
beams and anchoring them thereby leveling up to the top
of the sleepers with concrete, and then laying a double flixir,
as just descril^ed.

The obvious objections to w<X)d as a flooring material
will, of coui-se, apply to all wood floors, and they should

142 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

never be used exoept where necessitated by lack of means.
A cement floor will cost but little more than a good wood
floor, and is certainly far better in sanitation, permanence
and ultimate economy.

The best material for wall and ceiling finish is " Keen's "
cement, the best brands being imported from England,
where it is more largely used in hospital construction than
here. When properly applied it presents a very dense,
hard surface, and, skillfully worked, is capable of great
smoothness and polish. Incidentally it may be mentioned
that it is the basis of artificial marbles. The cost of this ma-
terial is a great drawback, and in ordinary work its use is
limited to wainscots, bases, window sills, and similar exposed
places. For the upper part of the walls and for ceilings
patent plaster or " dry mortar " answers very well, though,
while not so dense or hard as the " Keen's " cement, it is a
great improvement over common lime mortar. "Patent
plaster" is merely a basis of plaster of Paris mixed with
sand and a retarding agent, kept secret by the makers,
which slows the setting of the plaster of Paris suflSciently
to allow the walls to be properly worked. The mixing and
proportioning of patent plasters is done by machinery, and
is consequently done in a more thorough manner than if
done by the hand of an indifferent laborer, which is one
reason for its superiority over common plastering mortar.

The angles formed by the walls, and the walls and ceil-
ings, should be " rounded " or finished with a cove, instead
of forming a sharp comer. This cove should not be too
large, as it will be liable to crack if formed with a large
radius. A radius of two inches will be found sufficient for
all purposes, and is easily made.

The forming of the curve in wall and ceiling angles,
while simple, requires a considerable degree of care and
skill on the part of the plasterer to make it straight and
true, and to make all miters and intersections meet and
join properly.

The angle between the floor and wall should be coved

^\SEPSIH AND ANTISEPSIS IN SITRGBRY. 143

in the same manner, and where a tile, mosaic, or cement
floor is used there is no trouble ; where a wood floor is
used, however, it is impossible to make a joint or connec-
tion between the wood and plaster which will not open,
even if it be made tight when first put down. This is an-
other strong objection to the wood floor.

If tile be used for a wainscot or wall finish the coved
corners are formed in the tile themselves, and, if necessary,
special tile may be designed to suit different conditions or
positions.

The demands of hospital design present little that can
not be provided in constructiou as far as walls, floors, and
ceilings are concerned. With dooi-a and windows the case
is different, and it is here especially that future study and
invention are to be employed.

The difliculties pi-esented may be best appreciated by
referring to drawings. Fig. 76 shows a window frame and
sash in oi-dinary work, and in fact even in some hospital
work. A glance will show how unfit it is for any use
where it is essential to obtain thorough cleanliness; the
comers and angles offer abundant opportunity for the col-
lection of dust, which will increase as the wood shrinks
and joints open.

Fig. 77 shows a window designed to offer as far as pos-
sible the least ciiance for the lodgment of dirt and least ob-
struction to its removal, but even this construction leaves
much to be desired. The angle, A, between the easing and
jamb has to be covered with a molding, because it is im-
possible to make the wood and plaster join together closely
enough to avoid a ragged joint, and even with this mold-
ing there will be an open joint somewhere unless the work-
manship is far above the average ; and the sash itself offers
a 8hai*p angle lietween the glass and wood, which it is as
yet impossible to avoid.

The stop bead against the stile offers another joint, Ji,
which is sure to open through tlie effect of atmospheric
changes ; still, the improvement of one over the other is

144 BLECTEO-H^MOSTASIS IN OPEEATIVE SURGBBT.

quite encouraging, and the time will undoubtedly come
when many present objections will be overcome.

SECTION
THROUGH JAMB

WINDOW FRAME

MASONRY WALLS

ELEVATION OF
INSIDE LOWER CORNER

What 18 true of the windows is equally true of the
doors. Fig. 78 shows a door in an ordinary twelve-inch

ASKl-SLS AND ANTISEPSIS IN SURGERY.

partition finished in tlie usual way, and Fig. 79 shows the
best that can be done at present in the way of elimination
of the corners, joints, etc., which remain and are objection-

SECTION

THROUGH JAMB

5KETCH OF

IMPROVED FORM

OFWINDOW FRAME

m MA50NRY WALL5

FOR H05P1TAL USE

ELEVATION OT IMSIDE LOWER CORNER

able, but at j^resent unavoidable. Where the partition of
wall is less than five or six inches thick it is uecessar)' t*»
have a casino on one side, and in a two- or three-inch wall a
casiiig on both sides is necessary. (See Fig. 80.)

146 electro-h^:mostasi8 in operative surgery.

Where a casing is used, the cove at the floor is inter-
rupted, and more corners formed. The wood casing is
usually received by a marble base block, which prevents

UPPER CORNEF

SKrrCH OF USUAL FORM
OF DOOR FRAME
AND F1MI5H

rN THICK WALL5

PLASTEH

woodthim-^
SECTION THROUGH JAMB

ASEPSIS AND ANTISEPSIS IN SURGERY.

147

the casing reaching to the floor, where it is liable to injury
by frequent wetting in washing.

ELEVATION

UPPER CORNER

PLASTER

ROUNDED "-^x ^.' -i' -;m • -' w M "A^

CORNER p.^J.^'.^'^-^'^'^'<t\y<*

VEHEERCD DOOR

PLAIN JAMB

WALL

SKETCH OF
IMPROVED FORM
OF DOOR FRAME
ANDFmi5H f

FOR HOSPITALS /

•is:)!

PLASTER
ROUNDED CORNER

SECTION THROUGH
JAM B

Fig. 79.

Where the casing is omitted, the cove at the floor re-
turns around the wall jamb, or finishes against the wood
door jamb.

With reference to the doors themselves, the usual pan-

148

electro-ii^:mostasi8 in operative surgery.

eled door is obviously objectionable, on account of the
numerous sharp comers and angles.

The best substitute for practical use is a " solid ve-

ELEVATION

UPPEP COONEPI

VENCEPCD DOOR

PUIN JAMB'
WOODTRIM

v.. a *.'.•»,

E-WALL

mm^.

PLASTER

SECTION THROUGH JAMB

SKETCH SHOWING IMPROVED f=ORVl

OF DOOR FRAME AND FINISH, WHEN
NCCE35ARY TO USJW OOD TRIM.

A-'TOG'
WALL

SECTION THROUGH JAMB

Pia. 80.

ASEPSIS AND ANTISEPSIS IN SURGERY. 149

neered '* door ; that is, a door formed of a glued-up pine
core, and veneered on sides and edges with a hardwood
veneer, forming a perfectly plain surface, which may be
kept filled and polished*

Marble doors have been used to a very limited extent,
but they are heavy and expensive, hard to move, and unless
the hinges or pivots are very hard, and carefully made and
adjusted, they are liable to wear down and sag. The mar-
ble, however, is porous, easily stained, and altogether the
most objectionable of alL Bronze doore would answer best,
but they are too expensive for hospitals as a general rule.

HOSPITAL PLUMBING

In the matter of plumbing, improvements in material
and fixtures have reduced in a great degree many of the
difficulties formerly encountered in the proi>er equipment
of hospitals. Fixtures for almost all purposes are now
made of heavy glazed earthenware, in designs or forms
needing no encasing or surrounding material. A porcelain
bath tub is a typical example ; when set it is complete, no
wood curbing or boxing being required, as in the case of
the older copper-lined tub.

The price of these earthenware goods is practically
within the reach of an institution with but limited means ;
for instance, they are now being used in a certain small vil-
lage hospital, costing less than eight thousand dollars.

In some ways, however, the " improvements " in modem
plumbing fixtures are of doubtful character, such as a wash
basin with supply and waste cr>cks operated by treadles on
the floor. In a general way the questionable value of these
improvements lies in their complexity, rendering them diffi-
cult to keep clean or to keep in order. The number of
valve mechanisms, traps, wastes, etc., is almost ^^dthout end,
while the really desirable patterns are very few.

In short, the simplest form of any fixture with its acces-
sories is always the best, provided the construction is satis-
factorj'. A plain " S ^ trap with vent connection seems at

150 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

the present stage of progress to be the best to be had, and
a " standing " waste and overflow the most satisfactory for
general use. By a " standing " waste and overflow is meant
a simple tube whose lower end fills the outlet of bowl, sink,
or tub, and whose upper end is open, the tube standing
vertically, and its height determining the depth of water in
the fixture. Such a waste is the simplest possible thing to
keep clean, and, being wholly exposed, is always open for
complete inspection.

The trap should in all cases be placed as near the outlet
of the fixture as it is possible to get it, and the waste from
fixture to trap should be perfectly straight. The strainer
in the outlet of the fixture should be removable so that the
waste can be thoroughly cleaned.

The bad air in many bath and toilet rooms is due to the
fouling of the inaccessible waste and overflow connections
from fixture outlets to traps, and these same connections
may easily form favorable germinating places for dangerous
bacilli.

The whole aim in the plumbing of a hospital, as well as
any building, should be the greatest possible simplicity.
The number of fixtures should be cut down to the lowest
possible minimum, they should be grouped together as
nearly as possible to a few vertical lines, and the fixtures
themselves should be of the best material and plainest
design and construction consistent with specific require-
ments.

The arrangement of fixtures in the various rooms
should be such as to permit all piping to and from them to
be run in the most direct manner and so as to make the
distance from main lines of supply and waste as short and
as straight as possible. All waste pipes should have a
pitch of not less than one quarter of an inch to a foot. All
bends should be of large radius and clean-outs placed at
frequent and readily accessible points. All connections, at
least in the rooms containing the fixtures, should be made
with screw joints, so as to be easily taken down and put up.

ASEPSIS AND ANTISEPSIS IN SURGERY. 151

Where the means at hand will permit, the main lines of
waste, soil, and vent pipes should be of galvanized wrought
iron screwed together, rather than the usual form of cast
iron with lead calked joints which can not be depended
upon to remain tight

The principle of placing all bathrooms, water-closets,
etc^ in a pavilion separate from the hospital wards is good.
In such an arrangement the pavilion is reached by short,
connecting corridors having openings on both sides so that a
cross current of fresh air is always maintained between the
main building and the pavilion containing the plumbing.
This separation, of course, requires space and money, and
may not always be had ; some modifications costing less
may, however, be within reach, and the nearer the ap-
proach to the ideal the more satisfactory will be the result

Whether the plumbing fixtures are contained in a sepa-
rate pavilion or inclosed in the main building, the main ver-
tical lines of piping should be placed in a specially arranged
vertical shaft extending from the house drain at bottom up
to and above the root This shaft should be large enough
to peimit of the proper spacing and arrangement of all
pipes, and for a man to conveniently reach all connec-
tions and branches to fixtures. The branches to fixtures
should be run in this shaft so that there would be only the
supply cocks and trap visible in the room. If impossible
to reach a fixture by a branch in the shaft, then only vso
much as is necessary should be run on the ceiling of the
room below so as to avoid horizontal pipes at or near the
floor, as these present almost insurmountable obstacles to
thorough cleaning.

The vertical shaft containing the main pipes should have

open iron gratings at floor levels instead of solid floors, and

should have no openings into it except a small "manhole "

or door at the bottom, the various floor levels being reached

by an iron ladder built in the shaft itself. To complete the

scheme the shaft should be heated so as to produce a strong

upward draught in the soil, waste, and vent pipes and their
11

152 ELECTRO-H^MOSTASIS IN OPERATIVE SURGERY.

branches, so as to quickly and thoroughly oxidize any or-
ganic matter adhering to their sides.

Floor drains should be avoided as far as possible, and
where necessary should discharge into a water-supplied sink
placed in a shaft as already described or in a room below.
The sink being connected to the waste pipe in the same
manner as other fixtures, the outlet in the floor should have
a cover which could not be closed until a cap had been
screwed down over the waste, thus insuring complete isola-
tion of the floor drain from the main drains and wastes.

The sink or basin in an operating room should discharge
in the same manner as the floor drains, so as to have no di-
rect connection with the drainage system.

Polished brass or nickel-plated piping requires too much
time in cleaning for general use ; unpolished brass pipe and
fittings, painted with enamel paint, will be found more ser-
viceable where economy of labor is to be considered.

Much attention and care is necessary to make water-
tight connections where pipes pass through tile or similar
flooring, especially hot- water pipes, so that the floors may be
thoroughly washed without leaking.

HEATING AND VENTILATION OF HOSPITALS

Possibly no part of hospital construction has received
more attention than the heating and ventilating. The
amount of fresh air required for each patient and its tem-
perature have both been satisfactorily determined ; the prac-
tical operation of supplying the air, warming it, and causing
it to circulate completely throughout the whole of each
room is beset with many difficulties. For ordinary work it
has been found more desirable to divide the problem into
two distinct parts, one the heating and the other the venti-
lating. In this method the air is heated, by large heating
stacks located in the lower part of the building, to the tem-
perature desired for the room, say 70° F., the air being at
this comparatively low temperature can not counteract the
cooling effect of doors and windows and walls ; to do this

ASEPSIS AND ANTISEPSIS IN SURGERY.

^V direct radiators are placed at proper points in the rooms to
^H be lieated. This system works well, but the diiect radi-
^^ ators in the rooma rapidly collect duet and ai-e very difficult
to clean. A more satisfactory but a more expensive method
consists in heating the whole volume of air, at a central
point or station, to nearly the temperature required bj' the
various rooms, the air passing along main ducts or con-
duits to the vertical flues leading to the rooms. At the
base of each vertical flue is ].)laced a separate and inde-
pendent stack or indirect radiator, which further heats the
air to the temperature required. In this method, every
room governing its own temperature, the air may be suffi-
ciently wanned to overcome the cooling effect of outside
walls, doors, and windows. This method would probably
he as near an ideal scheme as possible to provide.

The matter of automatic control of heating surfaces,
such as stacks and radiators, has been bi'ought very near
perfection by various forms of thermostatic valves ofwrated
by the temperature of the rooms they conti-oL These valves
have been found to act with great certainty, so that the
temperature may be maintained within a variation of a
degree above or below the required temiterature. The
thermostatic valves are applicable to both systems described
above, and as it eliminates the necessity of depending upon
attendants to operate hand valves, the temperature ia more
uniformly maintained.

In the best work the air is filtered through screens of
gauze I>efore enteiing the heating chaml>ers. These screens
take out nearly all the dust, s<i tliat the air in the flues and
ducts is practically clean. A further application of the
screen system to 8|>ecial rooms, such as operating rooms,
would be of great advantage.

It has been found that by passing the au- through screens
formed of sterilized cotton batting it is not (miy cleaned of
dust but is also sterilized, and the advantages of sterilized
air in an operating room is of coui"se obvious. This steri-
lizing is readily accomplished by arranging a set of cotton-

154 ELECTBO-H^MOSTASIS IN OPERATIVE SURGERY.

batting screens in the flue leading to the room where ster-
ilized air is required, the screens being made somewhat upon
the principle of a photographer's '' plate-holder," allowing
the frame to be withdrawn for the purpose of changing the
cotton from time to time, the frame sliding in and out of a
trunk or other device built in the flue in very much the
same manner as a plate-holder is put into a camera.

The increased resistance offered by the cotton would
of course require a stronger draught or pressui*e of air in
the flue, but there is nothing in the scheme which would
make it impracticable.

Direct-indirect radiation should never be used where an
indirect system can possibly be afforded.

The direct-indirect scheme, as is well known, consists of
a radiator with a " box base,'* into which air is admitted
through an opening in the wall directly behind it, the air
entering the base of the radiator passes over it, and, be-
coming heated, enters the room. It is impossible to prop-
erly filter the air with this method, and it is also impossible
to properly regulate the temperature or supply. As a mat-
ter of economy it may answer for some small unimportant
rooms in case an outlet flue is provided leading to a main
exhaust stack or duct.

Storerooms, clothesroom, and closets should not be over-
looked, but should have as thorough ventilation as any other
rooms. This is often neglected.

Lavatories and rooms containing water-closets and
urinals should be ventilated through the fixtures — that is,
the air should be drawn out of the room through the bowls
of the fixtures themselves and conveyed by separate flues
to the top of the building. In this way all odor may be
entirely eliminated from these rooms.

No building can be thoroughly ventilated without the
use of a mechanical system, including the use of fans or
blowers. Generally, it will be found best to provide two
sets of fans, one to force air into the rooms and the other
to draw it out.

ASEPSIS AND ANTISEPSIS IN SURGERY. 155

All rooms should be under a slight pressure, so that the
warm air of the room will be escaping through the cracks
and openings around doors and windows instead of the
cold air outside leaking in and causing draughts.

Double sash or double glazing will be found of great
service in making the temperature of a room more uniform,
as well as reducing the consumption of fuel. It will also
have the effect of reducing the cost of the whole plant, as
the glass in windows is by far the most effective medium
in cooling the air, and is a very important factor in deter-
mining and proportioning the heating surfaces and other
parts of the heating system.

The system of exhaust flues and ducts is quite as im-
portant as the supply, and should be as carefully developed.

The location of registers in the rooms is also a very im-
portant item in securing a complete circulation of air in all
parts of the room. Experience has demonstrated that they
should both be placed on the same side of a room and near
together, the supply being about eight feet above the floor
and the exhaust at or near the floor level.

In furnishing hospital rooms and wards the same rules
should be followed as in the construction of the building.
The furniture should be such as will not lodge dirt or
absorb the germs of disease. Simplicity in design and
construction guards against the accumulation of dust and
dirt, and the material used should be impenetrable as far
as possible. Metal bedsteads and washstands are the best
in use at the present time when well plated. When these
expensive articles can not be afforded, white enamel iron
answers as well. Bureaus and cabinets should not be used
as a rule ; but if permitted, to please lady patients, they
should be severely plain, and enameled within and without.
Such furniture is easily kept clean all the time, and can be
sterilized when the room is treated by disinfection in the
way to be hereafter described.

CHAPTER XVI

ASEPSIS AND ANTISEPSIS (CONTINUED)

According to my observations most of the imperfec-
tions in carrying out aseptic methods in surgery occur in
admission of patients and the management of their clothing.
To guard against all possible iiifection from without the
hospital requires a thorough disinfection of everything
which comes into the building. Patients do not always
know that they have been exposed to contagious disease ;
sometimes they will not admit the exposure if they do know
of it. One may not disregard this possible danger of pa-
tients bringing from infected parts of the city sepsis and
infectious diseases. The only safe course is to insist upon
the sterilization of every new patient immediately upon
her arrival and the disinfection of all her clothing.

The method which I practice is as follows : The patient
is at once taken to the dressing room adjoining the bath-
room, where her clothing is removed and put into a clean
bag and sent to the sterilizer. She leaves her street costume
here and is conducted to the bathroom to receive an ammo-
nia bath, and then dressed in a full change of clothing,
which had been sent to the hospital the previous day and
sterilized. All her clothing and everything which she has
brought with her is sterilized by formaldehyde before being
taken to her room. By this means the surgeon will assure
himself that his new patient has at least rightly begun her
hospital life.

The Preparation of a Patient for all Major Operations.
— The previous night she receives a full ammonia bath, in
giving which the nurse is careful to clean all folds of the

156

ASEPSIS AND ANTISEPSIS IN SUKGEIIY. 157

skin. It is to be kept in mind that the nnrse in i-hai^ of
tlie bath must herself be clean. Thorough siTubbing
should be jiraoticed and then the body rinsed <»ff \vitli
boiled water. The head should be 9hami«.)oed with alcohol
and quickly dried. This having been accomplished, the
patient is dressed in sterilized under and night clothes and
then put into the bed newly made up with sterilized Ijedding
and beilclothes. A further cleauaing is now given the
whole abdomen in cases of abdominal section ; it is thor-
oughly scrublietl with soap and \\ater, then washed off with
a one-in-two-thousand bichloride solution ; finally, a bichlo-
tide compress (one in one thousand) and a clean binder are
put on. The nest morning this last cleansing pi-ocess is
i-epeated and a new compress and binder are applied. Now
that the jiatient is clean, the utmost care must be exercised
to protect her against contamination. She must be con-
veyed to the anaesthetizing room in a clean carriage or
stretcher by clean attendiuits. The aiuegthetist and the at-
tending nurses are dressed in clean garments. The anaes-
thetizing instruments have been cleaned the same as the
instmments for the o]>eration. If the narcosis is not given
while the patient remains in her carriage, the coucli or table
on which she is placed is to be covered with sterilized ma-
terial. As soon as the patient does not recognize her sur-
roundings she is finally jtrejiared for the operation by
scrubbing the abdomen with soaj) and water, the hypogiis-
trium is then shaved with a sterilized razor, dried and
bathed first in alcohol, then ether, and finally bicldoride
solution, one in one thousand. The umbilicus is covered
with collodion, in ease it is not to be incised ; a clean com-
press and a new binder complete all and the patient is ready
to be taken into the operation.

The room used f<jr operations is twice cleaned, once just
after the preceding operation and again in preparation for
the next one. Everything which is needed for the opera-
tion, except infitriinieiits, is IjiMuglit In : then the formalde-
liyde is introduced, antl tlie room sealet] for five hours.

158 ELECTRO-H^MOSTASTS IN OPERATIVE SURGERY.

Blunt instruments are sterilized by exposure in live
steam for fifteen minutes ; edged instruments are immersed
in alcohol (ninety -five per cent) for ten minutes. Of late
instruments are sterilized in formaldehyde ; and I believe it
will prove to be the best method. When needed they are
placed into the trays and covered with hot carbolized solu-
tion. Formula: Carbolic acid, three per cent; glycerin,
twenty-two per cent ; water, seventy-five per cent. Natu-
ral sponges are washed for twenty-four hours in Javell
water, the grit is taken out, and then they are washed in
sterilized water ; they are preserved in five-per-cent carbolic
solution. A careful rinsing in running sterilized water
prepares them for immediate use. They should not be
used a second time in abdominal work. Gauze sponges,
the towels, binders, and gowns are cleansed by the ordinary
steam apparatus. The primary gauze dressing is prepared
in quantities by saturating it in a solution of carbolic acid,
one part to glycerin eight parts. It is always ready, and
requires but to have the excess of the solution rung out of
it with a sterilized towel immediately before using.

The suture material used is the ordinary braided silk,
which is sterilized perfectly by boiling in salicylated wax
for twenty hours, in five-hour fractions, with an hour inter-
val. Suture material prepared in this way is perfectly
sterile and can be kept so for any length of time. More
than that, it will remain sterile in the tissues as long as
silver wire. This was demonstrated by both laboratory
and clinical experiments many years ago.

Cleansing and sterilizing the hands has always been one
of the subjects which claim the most careful attention of
surgeons. Even at the present time all methods, and they
are many, are questioned regarding their efficiency or prac-
tical application. Without discussing the subject I shall
give the methods employed in my own practice and which
have given the best results in regard to both the patient
and the operator.

The method employed is as as follows : Soft green ster-

ASEPSIS AND ANTISEPSIS IN SURGERY. I59

ile soap is used with a sterile brush and running water that
has been sterilized by boiling or distillation. The soap is
thoroughly applied with the brush, then washed off in
the stream of water. This process is repeated four or five
times, according to the condition of the hands. The water
is made to play with force upon all parts of the hands and
arms until all particles of the soap and dirt are washed off.
Finally, the hands are placed in a solution of carbolic acid
three per cent, glycerin twenty-two per cent, and water
seventy-five per cent, and scrubbed or rubbed in with a
brush. The excess of the solution is wiped off with a clean
towel, and they are ready for use. This is sufficient treat-
ment of the hands, unless the surgeon has been contaminated
by examining or operating upon septic cases ; then a more
careful disinfection is necessary. In such conditions of the
hands more prolonged washing is employed, and then they
are thoroughly anointed with carbolic acid pure one part and
glycerin seven or eight parts. This is applied to the hands
and arms and rubbed in with a soft, clean brush and
allowed to remain about five minutes. It is then rapidly
washed off with a strong stream of rapid-running water.
The reason for doing this quickly is that the added water
develops the caustic properties of the carbolic acid so that
it will injure the skin if permitted to remain in contact
with it.

The advantages which this glycerin and carbolic-acid
solution has is that the glycerin neutralizes the caustic
properties of the acid and does not diminish its power as a
germicide. Furthermore, it keeps the hands in good condi-
tion. I am quite confident that this is a most satisfactory
way of treating the hands so far as sterilizing them, not on
the surface only but deep into the cuticle as far as germs
go. The mercuric solutions which I formerly used hard-
ened the skin and left living organisms beneath the crust
of sterilized tissue. This hardened epithelium became
softened in abdominal work and set free the livinof crerms
that escaped the sterilizing. That is one of the imperfec-

160 ELECTRO-HiEMOSTASIS IN OPERATIVE SURGERY.

tions of the usual way of cleaning the hands, which has
been pointed out, and has driven some surgeons to the use
of gloves while operating.

I prefer to wear gloves when examining doubtful cases,
dressing wounds, or handling pathological specimens, and
so keep the hands free from infecting germs that can not be
destroyed by the method of cleansing which I practice, or
any other method known to me.

There is but one objection to the carbolic and glycerin
solution, and that is the expense, but that is hardly worth
naming in view of the advantages given by its use.

The subject of room disinfection, which has been far
from satisfactory in the past, has been greatly improved of
late. Indeed, I feel sure that the recent improvements in
this direction meet the requirements.

The recent work of Ezra H. Wilson, M. D., is the most
perfect that is known to me ; and I give here, by permission,
his essay on this subject :

The requirements to be met in a proper disinfection of
an apartment in which there has been infectious diseases are :

First. Absolute disinfection ; by that is meant the
destraction of all infectious material.

Second. Ease and rapidity in application.

Third. Economy.

Fourth. The least possible damage to disinfected goods.

The best disinfectant applicable to infected goods such
as wearing apparel, bedding, etc., is heat in the form of
steam, and it is safe to say that up to the present time no
substitute has been found which will disinfect so thoroughly,
rapidly, and economically as steam. The objections to its
universal application are, that it can not be applied in the
disinfection of apartments (walls, floors, ceilings, etc.), and
that certain cheap grades of colored goods are often injured
by it. The disinfection of apartments by the mechanical
process of rubbing and scrubbing with disinfecting solutions,
while very thorough, is tedious, expensive, and often dam-
aging to painted and frescoed walls and ceilings.

If, therefore, an agent can be found which can be used
for the disinfection of apartments which will be an efficient

ASEPSIS AND ANTISEPSIS IN SURGEEY.

germicide and not cause any damage, it is very desirable to
investigate it. Such an agent we believe we have in for-
maldehyde gas, used in a proper manner and in proper
amounts. The original method was to produce the gas by
the oxidation of methyl alcohol in the presence of iuean-
deecent platinum or platinized asbestos, and that is the
nietliod now used in the many lamj^s now in the market,
and for which extravagant claims are made. There are
many objections to these lamps. In the first place, and
what is most important, they do not produce enough of the
gas to be of any value. Second, they involve the use of
an inflammable and explosive compound, the methyl alcohol,
in proximity to an open flame. Third, they have to be
lighted and shut up in a room where they ai-e hidden from
observation. Fourth, it is impossible in practice to regulate
the lamp so as to get the maximum amount of gas, and so
to allow of the escape of unoxidized methyl alcohol vapor.

Roux, Baudet, Trillat, and othei-s devised a method of
evolving formaldehyde gae from f*»rmalin. Formalin or
formol IS a saturated (forty per cent) solution of the gas
in water. If a quantity of formalin is mixed with an equal
quantity of a five- to ten-per-cent solution of calcium chloride,
it will be found that tne boiling point of the mixture is
considerably above 100° F. (103° to 106°), and the most
favorable temperature for evolving formaldehyde gas is
between 95° and 100° F. Thus nearly all the gas is evolved
before the mixture is giving ofi steam. Moreover, it pre-
vents the polymerization of the gas into trioxymethelene.

I will now describe an appai-atus for carrying out this
process.

The Apparidus U ptictfd in Ttfo Canet.

A vfo<^l(i/ve C(7^e.^Containing autoclave with gauge ;
thermometer; two handles and a tin case containing two
outlet tubes and a vnre to clean same.

Case of Accessories. — Special lamp and small can con-
taining alcohol to light same ; copper can for the formo-
chloral ; tin can for kerosene ; cotton wadding for stuffing
cracks in windows, doors, etc, ; pair of sj^ectatles to protect

162 ELBCTRO-H^MOSTASiS IN OPERATIVE SURGERY.

TrUlat Autoclave. — ^The vessel of the apparatus is made
of heavy copper which is silver-lined and has a capacity of
about one and one half gallons. The remainder of the
apparatus is mostly brass, highly polished and carefully
finished.

The cover of the autoclave, which rests on a rubber
band so that it can be tightened to avoid any leakage, is
equipped with a pressure gauge, a sleeve in which the ther-
mometer is placed and a stopcock by which one regulates
the escape of formaldehyde gas.

La/mp. — ^The apparatus is heated by means of a special
lamp, the flame of which is fed by kerosene vapors. By a
small screw one can regulate the heat, and by using the
pump occasionally one can increase the heat.

FormocMoral is a saturated solution of formic aldehyde
and a neutral or indifferent mineral salt and absolutely free
from methyl alcohol. When heated under pressure, formal-
dehyde vapors are evolved in a non-polymerized condition.

Before putting the formochloral into the autoclave, it
should be well mixed so as to distribute any precipitate
which may be in the same. This deposit is not an im-
purity, but on the contrary is one of the essential parts of
the solution.

Directions. — ^All cracks around windows, doors, fire-
places, etc., should be stuffed to reduce the possibility of
the gas escaping as far as possible.

The formochloral is put into the autoclave, which should
never be more than three quarters full, about one gallon or
ten pounds by weight maximum. The minimum should
not be less than a quart, or about two and one half pounds
by weight on account of the possibility of injuring the auto-
clave. One calculates that one pound of formochloral is
sufficient for 2,500 to 5,000 cubic feet of air space.

When tightening the cover, one should screw the op-
posite bolts little by little so as not to press on one side of
the rubber band.

The apparatus after being closed is placed in front of
the door of the room that is to be disinfected at a conven-
ient height so that the stopcock is level with the keyhole.

Carefully examine the outlet tube through which the
formaldehyde gas is allowed to escape and see that it is
free from any obstructions. Then put it through the key-

■ as M

ASEPSIS AND ANTISEPSIS IN SURGERY. JfiS

hole, allowing it to project inside of the room from about
four to six inches ; then attach it to the autoclave by means
of the screw bolt attached to the same. Put the thermome-
ter in place, close the stopcock, and light the lamp.

When the gauge indicates a pressure of a little over or
about three atmospheres, carefully open the stopcock little
by little, otherwise, should it be opened too rapidly, the
liquid in the autoclave is apt to force itself out through
the tube and is liable to produce disagreeable results, and
for this reason it is well to take the precaution of removing
the furniture and to cover cai-pets that may be directly in
the vicinity of where the outlet tube projects.

One knows that the gas flow is well regulated by the
very gradual falling of the pressure as indicated by the
gauge. The pressure should be kept as near as jjossible
between two and three atmospheres. The vaporization can
be considered finished in about one and one half hours
when two and one half pounds of formochloral is used ;
for the maximum charge, ten pounds, two hours suffices
ordinarily, and one must always stop the operation when
the thei-mometer is over 135° and the pressure is below
two or three atmospheres. When the operation is over
the outlet tube can be withdrawn and keyhole stopped.

It is preferable to allow the formaldehyde gas to re-
Diaio as long as possible, but from three to four hours' con-
tact is sufficient for a good disinfection. Afterward it is
necessary to air the apartment. To do this, enter rapidly,
wearing the glasses and, without breathing, t>j»eii the win-
dow. One half hour later, one can without inconvenience
enter the room. The order of formaldehyde can be neu-
tralized more rapidly by injecting a little ammonia into
the room.

After the apparatus is cooled remove the thermometer,
take off the cover of the autoclave, and empty the residue,
which should be in a liquid iorm. Clean with water and
dry with a linen i-ag.

It will be seen from the experiment that the oi^anisma
protected by the folds of blanket were not killed, and this
l)rings up another eonsideratitm, namely, that of |>enetra-
tion. No matter how valuable this agent in a free state
may be as a disinfector of sumrficially infected areas, such
as walls, floons and ceilings, it must be admitted that its

104 ELECTRO-IIil^:MOSTASIS IN OPEKATIVK SURGERY.

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ASEPSIS AND ANTISEPSIS IN SURGKRY.

irtft

power of penetration is not gi^eat, and although i^oinowhat
foreign to the subject of this pai>er, I will de^scribo 8onie
experiments which were made to test this matter of peno-
tration. These were made at the City Disinfwting Station
by R. B. F. Randolph, assistant bacteriologist.

Tablk 1

No.

Culture.

Anthrax

4ft

• •••••

Typhoid

S. P. A

Anthrax

Diphtheria . . .
S. P. A

Typhoid

Anthrax

Diphtheria . . .

O* IT, A

Typhoid

Anthrax

Diphtheria . . .
S. P. A

Typhoid . . . .

Anthrax

Diphtheria . . .
o* -t • A

Typhoid

Anthrax

Diphtheria . . .

0« -L • A

Typhoid

Anthrax

Diphtheria . . .

C7« 1* J\*.*>«..

Typhoid

Anthrax

LtH'ution.

Inside a straw mattress.

i«

((

»t

«(

Folded in the middle of an excolsior mattrom,

«(

Between mattress and feather bod.

t«

Surrounded by two layers of blankets.

It
tt
tt
tt
It
II
II
11
tt
It
It
It
t.
it
II

'* one layer of blanket.

" four layers of blankets.

eight

Kxposc'd on top of the pile of goods.

K<^uH>

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Mvi'd.
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MvcmI.

Died.
LiviMl.

Diinl.

Experiment No. 2

A Trillat autoclave waw ho arranged that a Htreani of
fonnaldehyde gaw could be forced into the inner chamber of
the disinfecting oven. Sterile silk threadn were ininierHed in
cultures of Hporulating anthrax, B. typhoHuw, J{. dii>htheritt%
and 8taphyloc^)ccuH pyogenes aureuH, and allowe<I to dry at
ordinary temperaturew. When dry they wi^re in(rloM(*(l in
sterile filter-f)aper envelopes and arrangwl as desi^ribed in
Table 1.

The conditions of the experinx'nt were as follows:

Quantity of fonnochloral used, 1,250 c. c.

Capacity of the chamber, MO cn\>Ui feet.

166 ELECTRO-H^]MOSTASIS IN OPERATIVE SURGERY.

Vacuum at the beginning of the test, 14 inches of
mercury.

Vacuum after the admission of the formaldehyde, 11
inches.

Gas was run in for thirty minutes.

After the gas had ceased to flow, air was admitted until
the gauge stood at zero.

One hour after the gas was shut off the chamber was
twice exhausted and filled with air.

The chamber was opened at 10 a. m. the following day.

There was a slight odor of formaldehyde, but not enough
to prevent a man from going in immediately. About two
gallons of water smelling strongly of the gas was found on
the floor of the chamber. The goods were dry and uninjured.

It will be seen that the disinfection was far from com-
plete, the anthrax not being killed except in one instance,
and the other organisms in the more protected portions of
the pile not being affected. This lack of penetration, how-
ever, can be partially accounted for. The air admitted to
the chamber immediately after the gas was shut off was
taken through the sewer outlet, and in doing this the con-
tents of the trap were sucked up into the chamber and
possibly dissolved, and thus rendered inoperative a large
amount of the gas.

It was thought that a greater and more uniform degree
of penetration could be secured by slightly heating the
chamber, inasmuch as the diffusion power of a gas is
largely influenced by its temperature. The following ex-
penment was therefore made :

The formaldehyde was generated in an autoclave built
for that purpose by the Kny-Scheerer Co. It consisted of
a copper boiler nickeled inside and out and provided with
a water gauge, safety valve, thermometer, and exit tubes for
the gas evolved. Heat was produced by a triple "Pris-
mus ' oil burner. The apparatus was connected with the
disinfecting chamber by a rubber tube which connected
with a small iron pipe entering the chamber at the top.
The formaldehyde was generated from a mixture of Kny-
Scheerer formalin 38.7 per cent of CH^O. The mixture
was made up as follows :

Formalin 1,350 c. c.

Calcium chloride (anhydrous) 200 grs.

Water to make up to 4,000 c. e.

ASEPSIS AND ANTISEPSIS IN SURGERY. HJ7

The determination of formaldehyde was made by the
ammonia method aa given by Struver (Zeit. f. Hyg,, Bd.
XXV, Heft 2).

All determinations were made iu duplicate by both
gravimetric and volumetric methods. It would have been
advisable to determine the amount of mythyl alcohol in the
formalin, as this reacts with formaldehyde at the tempera-
ture of the operation, giving methylal, a substance having
little or no aisinfectiug action. Any methyl alcohol pres-
ent, therefore, diminishes the efficiency of the formalin.
No satisfactory method of determining methyl alcohol in
such a mixture has yet been devised, and the results of
this experiment are therefore subject to a correction on
this account. We have been assured by the manufacturer
of the formalin used, however, that it contains less than
one per cent of methyl alcohol, and no serious error wUl
be made by neglecting it.

Silk threads were soaked for several hours in twenty-
four-hour cultures of the bacteria used, and dried at room
temperatures. These threads were then inclosed in sterile
filter-paper envelopes as in the previous exfieriment, and
wei'e arranged as shown in Table 2, which also shows the
result of the experiment.

Table 3

OrKMiaiD uaecl.

LocaUop,

Renin.

Within & folded mutlress.
In the middle of a. folded blanket.
Between two folded lilatikets.
Exposed on top of pile.

Killed.

Diphtheria

^H The pile of material was placed on the truck and run 1
^H into the oven, being as nearly as possible in the center of 1
^B the chamber. The doors were then tightly closed and J

L J

168 ELECTRO-n^MOSTASIS IN OPERATIVE SURGERY.

the vacuum pump started, and steam turned into the outer
jacket in order to heat the inner chamber. In thirty
minutes a vacuum of 14.25 inches was obtained, and the
temperature of the inner chamber was then 40^ C. In the
meantime the lamp under the autoclave had been lighted,
and the pressure raised to 37.5 pounds. The valves were
then opened and the formaldehyde gas admitted to the
chamber, the pressure of the autoclave being kept above
30 pounds. The gas was allowed to flow thirty minutes
and was then shut off, the vacuum in the chamber having
fallen to 10 inches and the temperature risen to 49° C.
Air was then admitted to the chamber through the safety
valve until the vacuum was reduced to zero. The temper-
ature of the inner chamber was then raised to 65° C. and
kept there during the rest of the experiment, which lasted
altogether an hour and a half. At the expiration of this
time the chamber was opened, the threads in the enve-
lopes were removed and taken to the laboratory, where
they were planted in sterile broth and incubated for a
week. No moist cultures were used, as it was intended to
make the experiment correspond as closely as possible to
actual working conditions, and in practice we are seldom
called upon to disinfect articles that are not dry. The for-
malin mixture remaining in the autoclave was carefully
removed and measured. It amounted to 2,300 c. c. and con-
tained 9.27 per cent of formaldehyde, corresponding to
213.2 grammes. As the original mixture contained 500
grammes 286.8 were present in the chamber, and as the
capacity of the chamber is 10,188 cubic metres, each cubic
metre contains 28.11 grammes of CHjjO. This corresponds
to a volume per cent of 1.93, or, in round numbers, two per
cent.

This experiment proves that, under the conditions
adoped, two per cent is sufficient to disinfect anthrax
spores in the middle of a mattress — a very severe test —
and, on this account, it is recommended that two per cent
be the minimum of gas allowed. As regards the temper-
ature and the vacuum, the experiment shows that a temper-
ature of 65° C. is high enough, and that a vacuum of at
least half an atmosphere is desirable.

It will be seen that the temperature exercises a marked
effect on the disinfection, and the failure of the first experi-

ASKPSIS AM) ANTISEPSIS IN SURGEUY. Hi'j

raent, wliere a much larger percentage of gas was used,
must be attributett to the low temperature at which it was
conducted.

This method, therefore, gives a convenient and satisfac-
tory disinfection of goods that would certainly be injured,
if not riiined, by the use of sfeam.

The advantages of the autoclave over the lanijis are
at once apparent :

First. It produces a large volume of the gas.

Second. Rapidity of application.

Third. It is couHtautly under observation and located
outside the room.

Fourth. No damage to disinfected goods.

CLEANLINESS IN THE CAKE OF PATIENTS AND SICK ROOMS

The older methods of disposing of soiled clothing,
dressings, and discharges were most objectionable. Old foul
dressings were carried fi-om the halls, some of them to the
laundry, to be washed and used again. Excrements were
carried in open vessels to the closets, deposited there, and
in the best-regulated hospitals or homes some disinfectant
poured down the closet every time it was used, or several
times a day, and the results were easily to be imagined.

The metliods pursued at the ])resent time in my practice
are to place all soiled di'essings directly on their removal into
a vessel The vessel is closed with an air-tight rubber cover
and taken away and the dressings at once cremated. The
vessel is disinfected at once, and made I'cady for fuilher use.
Vessels used for the reception of excrement, urinals included,
receive before using some disinfectant and deodorizer, and
when used are covered with air-tight rubber covei-s and
taken away. Wash basins are emptied into slop pails that
can be closed with rubber covers while conveying them to
the closets to be emptied and cleansed.

Bed linen is placed in a clean bag of rubber cloth and
conveyed to the laun<lry. In this way the halls, stairways,
and elevator are kept free fn}m contamination and mal-
odoi-a.

INDEX

Abdominal incision, hsemorrhage, 30.
Abscess, pelvic, 85.
Acetic acid, 104.
Adenomectomy, 97, 100.
Adhesions, not possible, 25.

of appendix vermiformis, 32.

of bladder, 34.

of intestines, 33, 52.

of omentum, 31, 52.

of rectum, 34.

recent, 35.

vascular, old, 55.
Advantages of method, 25, 83, 134.
Anaesthesia, 64, 77, 119.
Angioma, 115, 132.

of urethra, 113.
Antisepsis and asepsis, 136 et seq.
Appendectomy, 57.
Appendix vermiformis, adhesions, 32.

treatment, 23.
Artery, treatment, 23.

treatment of isolated, 18.
Aspiration of Fallopian tube, 56.

Battery outfits, 14 et seq.
Belladonna tr., 124.
Bichloride of mercury, 77.
Bismuth subgallate, 124.
Bladder, adhesions, 34.

tumors, 102.

ulcer, 110, 118.

Cancer, of uterus, 65.

of cervix, 65, 69.

of bladder, 106.

cures, 83.
Carbolic acid, 77.
Carbuncle, 93.
Caruncle, 113.

Case histories — appendectomy, 60.

bladder, neoplasm, 107.

epithelioma of lip, 129.

Fallopian tube, patency, 49, 51.

fissura in ano, 128.

mammectomy, 3, 97, 99.

migrated ligature, 7, 51.

naevus, 129.

nsevus pilaris, 129.

ovariotomy, 50, 51.

post«mortem condition of stump, 6.
Catgut ligatures, objection to, 1, 25, 96.

for peritoneum, 83.
Caustics, 131.
Cautery, galvano, 129,

knife, 72, 78.

loop, 69.
Cervix, amputation, 45.
Clamp, ovariotomy, 35.

haemorrhoidal, 121.
Coagulation necrosis, 27, 29.
Cocaine, 127.
Current, strength of, 10, 13, 26, 130.

length of time to be maintained,
18.
Cystotomy, 102.
Cysts, labial, 87.

vaginal, 88.

Directions for use of instruments, 12.
Dome electrode, 75.
point, 32, 41, 55.
Doors, sanitary construction, 149.
Drainage in pelvic abscess, 86.
Dressings, disposal of soiled, 169.
Dry dissector, 40.

Electrolysis, 130.
Endoscope, glass, 118, 127.

171

172

ELEC^TRO-IM^IOSTASIS IN OPERATIVE SURGERY.

Epithelioma of cervix, 09.

of skin, 1:32.
Experiments, 23, 26, 29.
Experimental results, 21, 25, 29.

Fallopian tube, experiments, 26, 29.

patency, 0, 49, 51, 59.

operation upon, 49.

aspiration, 56.
Fibroid, 39 et seq.
Fissure of anus, 125.
Fissure of neck of bladder, 118.
Fistula of rectum, 57.
Flaxseed tea enema, 124, 125.
Floors, sanitary construction, 140.
Forceps, plain, 9.

hiPinorrhoidal, 121.

for ovariotomy, 35.

shield, laparotomy, 34.
elytrotomy, 80.

the dome, 32.

temperature required, 35.

time required, 18.
Formaldehyde disinfection, 160 et aeq.
French method for hysterectomy, 82, 84.
Friable tissue, 25, 132.

Galvano-cautery, 67, 129.
Glands, lymphatic, 100.

of urethra, 110.
Glycerin and carbolic for hands, 59.
Glycerrhiza comp. ext., 124.

Healing process, 23, 30, 107.
Heat, 10, 104, 152.
Htematocele, pudendal, 92.
llaunorrhage in abdominal section, 30.

capillary, 32.

control of, 25.

in sac of Douglas, 82.

secondary, 18.

with cautery knife, 73, 131.
ILomorrhoidal clamp, 121.
Ilunnorrhoids, 120.
Hernia, 30.

High amputation of cervix, 71.
Hospital construction, 137 et seq.
Hydrosalpinx, 52.
Hysterectomy, advantage of method, 83.

for cancer, abdominal, 65.
vaginal, 76.

for fibroid, 42.

mortality, 84.

Instruments, sterilization, 158.
Intestine, adhesions, 33.

protection to, 31.

operation upon, 23, 57.

Labial cysts, 87.
Laboratory experiments, 21, 23.
Ligature, objections to, 1, 25, 30, 32, 49.
Lymphatics, treatment, 25.

Mammectomy, 95.

Mesosalpinx treatment, 54.

Mortality of method, 84.

Mucous surfacjes, treatment, 23, 25, 57.

Myomectomy, 39.

Neoplasms, bladder, 102.

of mucous membranes and skin, 129.
Nerves are devitalized, 25.

Omentum, adhesions, 32, 52.

treatment, 31.
Opii comp. liq., 124.
Ovariotomv, 30.
Ovario-salpingectomy, 52.

Pain, 5, 25, 97, 138.
Pedicle, formation, 53.

forceps, small, 35.
large, 86, 37.

post-operationem, 5.

repair, 23.

treatment, 35 et seq.
Pelvic abscess, 85.
Peritoncjum, 37, 45, 72.

suturing of, 83.
Plumbing, sanitary, 149.
Preparatory treatment, haBmorrhoids,
120.

major operations, 156.
Pudendal wounds, 90.
Pyosalpinx, 54.

Reparative process, 23, 25, 59, 64, 107,

122.
with ligature, 5.
Recoveries incomplete with ligature, 49,

50.
Rheostat, 12.

Salpingectomy, 49.

Septic processes inhibited, 25, 60.

Sequela), ()i)erative, unfavorable, 5.

INDEX.

173

Shield forceps, 40, 80.
Silk ligatures post-operationem, 5.
Sloughing from pressure, 44.
Soda bicarbonate, 124.
Speculum, Byrne's, 68.
Sterilizing effect of method, 25.
Stump ablation, 58.

aseptic conditions, 25.

exudates, with ligature, 50, 59, 60.

ligation, 6.

conditions after treatment, 19, 63.

size after treatment, 25.

reparatory processes, 25.
Suture material, 158.

Temperature of heated forceps, 12.
Time necessary for desiccation, 18, 31,

81, 96, 121.
Transformer, 11.

Ulcer of bladder, 110, 118.
of rectum, 125.

Ureter, treatment, 23.
Urethra, glands of, 116.

papilloma of, 117.

stenosis of, 117.

Vagina, cysts of, 88.

disinfection of, 76.

hysterectomy through, 76.

indications for section of, 85.
Varix of vulva, 89.
Vascular tumors, 180.
Vaseline for forceps, 18, 36.
Ventilation, sterile, methods of, 152.
Vessels, treatment of, in hysterectomy,

43.
Volsellum forceps diverging, 72.
Voltage required, 11.
Vulva, diseases of, 85.

Walls, sanitary construction, 139.

Watts required, 10.

Windows, sanitary construction, 143.

LIST OF AUTHORS CITED

Armstrong, 57.
Barker, 100.
Beard, 135.
Bloom, 131.
Bovee, 51.
Byrne, 65, 135.
Ciirobak, 50.
Clark, 65.
Dickinson, 123.
Kmery, 137.
Ferguson, 6.
Haggard, 55.

Keith, 7, 49.
Kelly, 4, 47, 65.
Pignolet, 8.
Randolph, 165.
Ries, 49.
Routh, 88.
Schauta, 50.
Schleich, 64.
Seymour, 23.
Smith, 57.
Van Buren, 125.
Wilson, 160.

THE END

A TREATISE ON THE

DISEASES OF WOMEN

By ALEXANDER J. C. SKENE, M. D.,

PBOFE880B OF GTNJBOOLOOT IN THB LONG ULAND COLLSGB HOSPITAL, BBOOKLTN, N. T. ; FOB-
MBRLT PROFESSOR OF GTNiBCOLOGT IN THR NEW YORK POST'ORADUATB MEDICAL

SCHOOL AND HOSPITAL, BTC.

Third Edition, revised and enlarged. 8vo, 091 pages. With 200 Fine
Wood Engravings, and Nine Chromolithographs, prepared

especially for this work.

SOLD ONLY BY SUBSCRIPTION.

THIS attractive work is the outcome and represents the experience of a long and
active professional life, the greater part of which has been spent in the treat-
ment of the diseases of women. It is especially adapted to meet the wants
of the general practitioner, by enabling him to recognize this class of diseases as
he meets them in every-day practice and to treat them successfully.

The arrangement of subjects is such that they are discussed in their natural
order, and thus are more easily comprehended and remembered by the student.

Methods of operation have been much simplified by the author in his practice,
and it has been his endeavor to so describe the operative procedures adopted by
him, even to their minutest details, as to make his treatise a practical guide to the
gynaecologist.

While attention has been given to the surgical treatment of the diseases of
women, and many of the operations so simplified as to bring them within the
capabilities of the general surgeon, due regard has also been paid to the medical
management of this class of diseases.

Although all the subjects which are discussed in the various text-books on
gynaBcology have been treated by the author, it has been a prominent feature in
his plan to consider also those which are but incidentally, or not at all, mentioDed
in the text-books hitherto published, and yet which are constantly presenting
themselves to the practitioner for diagnosis and treatment.

**In the preface of the first edition of this work the author states : 'This work was written for
the purpose of bringing together the fully matured and esnential facts in the science and art of
gyneecoK)gy, so arrang^ as to meet the requirements of the student of medicine, and be convenient
to the practitioner for reference/ The demand for a second edition has demonstrated bow fully
this purpose has been accomplished. The reader can not fail to commend the conservatism and
honesty of the author *s opinions, and the care with which the material has been collected and
arranged. The second edition contains new chapters on Ectopic (testation, Diseases and lnjiiri(>B
of the Ureters, and Vesical Hernia. The first of these subjects receives in this edition a careful
exposition, the want of which was among the few defects of the former edition. The author's
work in the positional disorders of the uterus and laceration of the peri nteum stands pre-eminent
among the contributions to this sabject. His discussion of the use of pessaries throws mucn light upon
a subject which has suffered from the want of careful treatment, iKJth pro and con. The publishers
deserve great credit for the illustrations and general style^of the woT]s..—MediccU News.

" We have very little to add to what we said of it on its first appt^arance, and we still regard it as
one of the few foremost b<M)ks in this department in the English language. The addition of
chapters on Diseases and Injuries of the Ureters, and on Ectopic Gestation, make it more complete.
Too much praise can not be given to the Illustrations, which are models of cleaniess, and, as is not
always the case, show what is me&nV— Boston Medical and Surgical Journal.

D. APPLETON AND COMPANY, NEW YORK.

Medical Gynecology:

A TREATISE ON THE DISEASES OF WOMEN
FROM THE STANDPOINT OF THE PHYSICIAN.

By Alexander J. C. Skene, M. D.,

Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. ; for-
merly Professor of Gynecology in the New York Post-Graduate Medical School ;
Gynecologist to the Long Island College Hospital, etc.

8vOy ^j6 pages. With Illustrations. Cloth, $^,oo.

" The direction of modern gynecology has been almost entirely surgical, and it is
really refreshing to open a book of this description. The distinguished author has
filled a much-felt want in placing this volume before the profession. . . . Dr. Skene
has covered an almost untrodden ground, the great importance of which can not be
too highly appreciated. This work commends itself not only to the general prac-
titioner but to the specialist as well, who will find in its pages much important infor-
mation." — Annals of Gynecology and Pcediatry.

'* If by the publication of this book Dr. Skene accomplishes.no more than to direct
attention to the possibilities of the medical treatment of gynecological cases, and to
divert the minds of practitioners, especially the younger ones, from the idea that only
from surgery is relief in these cases to be looked for, he will do the profession and
the public an inestimable service. We predict for the volume a cordial reception on
the part of the profession wherever its merits are known, for there is no other book
of recent date which treats these subjects in the same practical and common-sense
manner." — Brooklyn Medical Journal,

" This is not a text-book, but better than a text-book to the practitioner. It is the
record of a ripe experience, and gives many facts, and calls attention to many condi-
tions that the mere text-books of the day can not reach. In short, it is a book that
ought to be read by the practitioner, and then there will be the need of many refer-
ences to its pages to refresh memory." — Virginia Medical Monthly.

*' In the rapid development of gynecology during recent years, the surgical side of
the subject has received the larger share of attention, thus in a measure leading to its
neglect from a medical standpoint. This excellent addition to the literature of med-
ical gynecology will aid in correcting this tendency and maintaining a just balance
between the medical and surgical phases of this department of our art. . . . The work
is an able and well-written presentation of the subject, and will no doubt be received
with the high degree of favor accorded to the various contributions of the author to
surgical gynecology." — Memphis Aledical Monthly.

" We have never read a more entertaining and profitable book. The purpose of
its popular author in contributing this his latest volume on gynecology is to outline
the purely medical aspect of the subject, and especially to draw the line clearly between
medical and surgical indications for treatment. . . . The general principles underlying
heredity, sexual types, and functions are described at length. All the functional and
organic disorders peculiar to women are discussed in an exceptionally rational and
practical manner. Throughout the pages of the book hygiene and prophylaxis are
given special attention. The book is altogether valuable and desirable, and ought to
be read by every medical student and practitioner, particularly the latter." — Denver
Medical limes.

D. APPLETON AND COMPANY, NEW YORK.

THE DISEASES OF
INFANCY AND CHILDHOOD.

For ilie Use of Students omd Prdetitioners of Medicine.

By L. EMMETT HOLT, A. M., M. D.,

Professor of Diseases of Children in ihe New Torh Ihly clinic ; Attending Physician to

the Babies^ Hospital and to the Nursery and Child? s Hospital^ New York;

Consulting Physician to the New York Infant Asylum^ and to the

Hospital for Ruptured and Crippled,

With 7 full-page Colored Plates and 203 Illustrations. Cloth, $6.00 ^

sheep, $7.00 ; half morocco, $7.50.

SOLD ONLY BY STIBSCRIFXION".

Am.ericaji Medico-Surgic&l Bulletin:

** This work is in every sense of the word a new book ; for, while the best work of other
authors in this and other countries has been drawn upon, especially that in the form of
monographs and in the files of psediatric literature, the m^jority is derived from the author's
own clinical observations. Obsolete dicta handed down from text-book to text-book are
here conspicuously absent, and nothing has been accepted which has not been carefully
tested. ... It is not venturing too much, after a careful perusal of these pages, to predict
for this volume a pre-eminent and lasting position among the treatises upon this subject.
We heartily recommend that it find a place not only in the library of every physician, but
wide open at the elbow of every man who desires to deal intelligently with the problems
which confront him in the treatment of infants and children intrusted to his care."

Nashville Jouma.1 of Medicine :

** This magnificent work is one of the most valuable recent contributions to medical liter-
ature. It will rapidly win its way to a front rank with other standard works upon kindred
subjects. It is as nearly complete as a treatise upon this subject can be.''

Virginia. Medical Semi-Monthly :

" When one recalls the teachings of a decade or two ago and compares the inculcations
of to-day, he can scarcely help recognizing that * old things have passed away, and all
tilings have become new.' The volume before us is practically the record of information
obtained by the author from eleven years of special study and practice, so that nearly every
subject is presented from the standpoint of personal observation and experience. The
information given is therefore reliable, for Dr. Holt is a close observer and a careful student
of his ripe experience. ... In short, this book appears to us to be the best all-round, up-to-
date book for practitioners and students of children's diseases that we know of."

Medical Progress :

" The work before us is one which reflects great credit upon the distinguished author.
Dr. Holt has long been known as a most industrious and painstaking investigator, and in
this volume he sustains tiiat reputation. The work, we may say in a sentence, is fully up
to the requirements of the times, and there is no advance known to paediatrics which has
not been fully dealt with according to its merits."

D. APPLETON AND COMPANY, NEW YORK.

THE MENOPAUSE

A CONSIDERATION OP THE PHENOMENA WHICH OCCUR TO

WOMEN AT THE CLOSE OP THE CHILDBEARING

PERIOD, WITH INCIDENTAL ALLUSIONS

TO THEIR RELATIONSHIP TO

MENSTRUATION.

Also a Particular Consideration of the Premature (especially the

Artificial) Menopattse.

By ANDREW F. CURRIER, A. B., M. D.,

NEW YORK CITY.

l^mo, 284 pages. Cloth, $2.00.

" Such a universally important topic as the menopause deserves the extended
consideration given it in this volume. The author takes the ground that this
period of woman's life is not so fraught with danger as taught in previous works on
the subject. He also corrects the prevalent idea of an intimate relationship be-
tween cancer and the menopause. Artificial menopause is carefully considered. It
is a most valuable book, and should be in the hands of every physician." — Nash-
ville Journal of Medicine a/nd Surgery,

** This is a remarkably interesting treatise upon a subject but scantily dealt with
by writers upon general medicine. The author has taken great pains to make a
thorough study of the topic, and his conclusions are arrived at by logical methods
of reasoning. He shows, what many medical men have long suspected, that the
climacteric is not of itself a cause of disease, and that normally it passes by with-
out observable effect." — Northwestern Lancet,

" This is a sensible, honest book. Through it the author has made a contribu-
tion to medical literature of more than ordinary value. This conclusion is reached
not because of the great intrinsic value of the facts adduced, but because every
page bears the earmarks of conscientious research. If Dr. Currier has not given
us more scientific knowledge than we possessed before, it is, we are convinced, be-
cause such. knowledge is unavailable." — Medical News,

" The monograph before us is certainly one which has been long demanded by
the medical profession. . . . Taken altogether this is a most excellent little book,
which we can heartily recommend to all physicians as the latest and most advanced
and consequently the best on the subject." — St, Louis Medical and Surgical
Journal.

D. APPLETON AND COMPANY, NEW YORK.

LANE MEDICAL LIBRARY

^^B. A

X68 Skene, A.J.C. 440^|
S62 lillectro-haemoataBis In

' D.ME I.V.

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